Here you will find the complete text of the Willcutts Report. First a little background.

James Forrestal was Secretary of the Navy during the last year of World War II. In September 1947, after consolidation of the Army and Navy, President Truman appointed him Secretary of Defense, the first person to hold that position. Forrestal later became outspoken in his criticism of certain policies of the Truman administration. We won’t go into the details or the smear campaign waged against him by Drew Pearson, Walter Winchell and others. Near the end of March 1949 Truman demanded Forrestal’s resignation, a move Forrestal had anticipated.

Forrestal’s successor was sworn in March 28. The next day the House Armed Services Committee held a ceremony lauding Forrestal’s military service, at which he gave a brief speech. Afterwards Stuart Symington, Secretary of the Air Force, sought out Forrestal and talked with him on their ride back to the Pentagon. Marx Leva, Forrestal’s top aide and who had an office next to his, found Forrestal profoundly changed after this meeting, preoccupied and absent minded. He informed Forrestal’s friend Ferdinand Eberstadt who then persuaded Forrestal to go with him to a vacation spot at Hobe Sound, on the east coast of southern Florida, for a rest. On March 31 Clifford Swanson, Surgeon General of the Navy, began proceedings to have Forrestal hospitalized if he so desired. Two days later Forrestal was flown from Hobe Sound back to Washington and admitted to Bethesda Naval Hospital suffering from what the doctors described as exhaustion and depression due to overwork.

He was placed on the 16th floor of the central tower in a suite with a small kitchen. By all accounts after a few weeks rest he had recovered, yet he was not released. Seven and a half weeks later, on May 22 a few minutes before 2 a.m., hospital personnel heard him landing on a roof 13 floors below the kitchen window, a bathrobe cord knotted around his neck.

A military board of investigation “for the purpose of inquiring into and reporting upon the circumstances attending the death of Mr. James V. Forrestal” was convened on May 23 by Morton D. Willcutts, Rear Admiral of the Navy’s Medical Corps, with Captain A. A. Marsteller as senior ranking officer. The proceedings lasted five days. The resulting report, approved July 13, 1949, is now known as the Willcutts Report. The Navy never published the report in full and it remained filed away and forgotten until April 2004, when David Martin discovered it using a Freedom of Information Act request. A PDF photocopy is at the Seeley G. Mudd Manuscript Library of Princeton University.

The HTML rendition of the Willcutts Report presented here has several advantages over the photocopy. It is much easier to read, your browser can find desired text instantly, Google can better index it, and you can easily and accurately quote the report using copy-paste. The ability to search will be especially useful since the report is a mass of unorganized detail.

Even a cursory reading of the report reveals that books about Forrestal seriously misrepresent what happened the evening of May 21st 1949. David Martin, who has made a specialty of exposing the chicanery of what he calls court historians and journalists, analyzes this in detail in his series of articles cited above. Forrestal has been called crazy, yet you will search the report in vain for such words as delusion, persecution, anxiety, paranoia.

The report begins rather boringly with 27 pages of official approvals, statements and endorsements. The meat is the Proceedings section, a transcript of witness testimony starting on photocopy page 28. This section’s pages are numbered 1 to 61 in the report, which are pages 28 to 88 of the photocopy. Then follows an untitled review of the evidence, and lastly an appendix of exhibits (including the most revealing Nurse’s Notes). The first 27 pages of the report – numbered 1 to 27 in the photocopy – are not part of the report proper, though it’s usually convenient to refer to everything as simply “the report.”

It is provided below uninterrupted by comment (except for bracketed notes on textual lapses) but a few remarks must be made at the outset. Forrestal had long antagonized two groups known for assassinating their opponents: communists and zionists. Any investigation of his death worthy of the name would have considered the very real possibility he had been murdered, “suicided” as the expression goes, yet this possibility is never explicitly raised in the report. The board members and the witnesses they call all seem to take for granted that Forrestal killed himself. The questions asked focus on one issue: Was anyone in the Naval Medical Corps responsible? The report is far from the very thorough inquiry it claims to be.

When in the report you read about providing Forrestal “security” it always means protecting him from himself, never from an outside threat. That he might have needed the latter kind of protection apparently never occurred to the hospital administration.

Everyone in the Medical Corps who dealt with Forrestal before his death seems worried about getting charged with incompetence. Their worry is understandable since they were responsible for preventing patients in the neuropsychiatric ward from injuring themselves. If Forrestal had to die, better for their reputation had it not been by suicide. If Forrestal had to die an unnatural death, better had it been murder. Thus the investigative board’s failure to consider the possibility of murder, given that it was a possibility, is all the more puzzling. Their naïveté, if such it was, was not in the Medical Corps’ interest.

In spite of ignoring the murder angle, the board never states flat out that the death was suicide, either. Winfred Overholser’s statement (photocopy page 2) is his opinion of the report rather than part of the report itself. In particular, he says: “From a study of the report, it is my opinion that Mr. James V. Forrestal came to his death by suicide while in a state of mental depression.” This is a gratuitous remark since the report, despite it insinuating suicide, reaches no conclusion regarding the ultimate cause of Forrestal’s death. It simply does not address the question. Neither of its two “Finding of Facts” sections (page 22 and page 88) mentions suicide, and its untitled review of evidence (page 89) states only that the hospital psychologists considered him a potential suicide and that they took a calculated risk, and then abruptly – too abruptly – ends.

Reading the transcript of witnesses, some pompous, some naïve, many apprehensive they will be charged with negligence, the impression gradually builds of a silent presence lurking over the proceedings: the ghost of unasked questions.

Things to Look for while Reading the Report

First of all, the report is worth reading. World War II and its immediate aftermath was a turning point in U.S. history which led to where we are today, and only a re-evaluation of that period can save us. If Forrestal, an outspoken critic both of Soviet fellow travelers and of bringing the Arab-Israeli conflict into domestic politics, was indeed silenced by an assassin, it is an important piece of history we need to know more about. The Willcutts Report provides evidence in the case, much of it without intending to.

The main thing to observe while reading the report is that besides being inconclusive regarding the cause of death the investigation was amazingly incomplete. The Medical Corps, its recorder and review board, again and again fail to consider obviously pertinent lines of inquiry. You can see the failure by considering the report alone, as if it were your only source of information about the case, and then you can see further omissions by examining other sources.

Here are some questions and observations that might occur to anyone while reading the report. You can click the small square buttons () to jump to an appropriate point in the Proceedings testimony. Click your browser’s back button, or press Backspace or Alt left-arrow, to return to where you were. (You can just ignore the small square buttons on first reading.)

Why would a man, angry that a newspaper columnist he despised had called him crazy, then prove it by leaping out a 16th story window?

The psychiatrist George Raines emphasizes that Forrestal was a fast mover, that “he moved like lightning.” (To go outside the world of the report for a moment, photos of Forrestal while alive show a man who carried himself exceptionally well. Such people are graceful, efficient in their movement.) Then Raines takes the ability to move rapidly to mean acting on impulse. But agility is not carelessness or impetuosity, they are completely different attributes. Agility is a positive quality and doesn’t entail anything negative.

Even by April 9 Forrestal was doing well. The following is from the Nurse’s Notes of that evening, photocopy pages 47 and 48 (exhibit 3 items #57 and #58). April 10, Hour 14:30 (original all in caps, some punctuation added here): “Pt. woke up. Struck up conversation with corpsman by saying ‘Prise, you must begin to regard your patients as animals in a zoo after a while.’ When I told him I didn’t he smiled and said ‘That’s good.’” Hour 16:00, after a visitor: “... Pt. in very good mood.”

On May 20th and again the 21st, the night Forrestal was to fall to his death an hour or two after midnight, a new man was assigned to the third shift watch. Why didn’t the board call the earlier third shift watch, C. F. Stuthers , to testify so that he could be asked what he usually did and experienced on duty, and compare it with what his replacement did and experienced?

What was the background of that replacement, Robert Wayne Harrison, who as it turns out had been assigned to the hospital only a week or so before steps were taken to admit Forrestal?

For that matter, what was the background of everyone at the hospital who could possibly have accessed Forrestal the night of May 21st?

It is easy to get the impression from the report that there were no other patients on the 16th floor, that Forrestal had the whole floor all to himself. But surely such an unusual situation would have been explicitly stated in the report, and it isn’t. Who then were the other patients and when were they admitted? Not only were these patients worth questioning because one of them might have seen or heard something unusual, what better way for an assassin to gain access to the floor than as a fake patient?

Common sense if not common or military law dictates that an unnatural death be presumed a potential homicide until proved otherwise. Why wasn’t at least one professional criminal investigator on the board of inquiry? An admiral may have executive ability and still be a fool when it comes to conducting a criminal investigation. The entertaining fraud Uri Geller fooled many a Ph.D. yet was quickly exposed by James Randi, a theatrical magician who knew the trickster business. When it came to investigating a homicide the board was no place for amateurs.

That said, at times it seems that only duplicity could account for the board’s otherwise inexplicable lack of curiosity.

Look at the photographs of Forrestal’s bedroom, exhibits 2H, 2J and 2K – especially 2K. A man lived in that room for seven weeks, has just met a death as unexpected as it was violent, and his bedroom looks like something out of Hotel Beautiful. Forrestal’s suite should have been treated as a crime scene, yet obviously someone had cleaned up before this photographic record was made. Nurse Dorothy Turner, who saw the room minutes after Forrestal’s death, describes slippers on the floor and a bed whose sheets are turned back. Who ordered the cleanup and why? The review board called one of at least two photographers as witness. He fails to say when he took his pictures and the board does not ask. Judging from sunlight streaming through the windows in the report exhibit pictures, they were taken several hours into the day. Why weren’t pictures taken about the same time as those of Forrestal’s body, soon after his fall, or if there were where are they?

At one point the board asks nurse Dorothy Turner: “You said you saw [Forrestal’s] slippers and a razor blade beside them; where did you see them?” Yet in the proceedings as transcribed in the report she had not mentioned seeing slippers, indeed no one had mentioned any slippers before this. She answers the question as if nothing were wrong with it.

Before the question alluded to above, Dorothy Turner had said she saw broken glass on the bed right after Forrestal was missed. The board ignores the broken glass, and fails to ask the obvious question: Were there signs of a struggle? For surely broken glass suggests this. In earlier testimony a photographer showed pictures of broken glass on the rug – taken he said about an hour after Forrestal’s death, though the picture put in the report may have been taken later – so the board members had had time to think about this evidence.

How long was the bathrobe cord found tied around Forrestal’s neck? (This information may be in exhibit 4, which is missing from the released report, but such an important detail should have been brought out in testimony as well.) What evidence was there, if any, that the cord had been tied to something else too, as insinuated by Raines? We are told the cord was unbroken. How could an intelligent man fail to securely tie a knot that many a six year old knows? What were the cord lengths to each side of the knot? The board gives short shrift to the most important piece of physical evidence in the case.

The cord when found is described as not tied tight enough to prevent breathing. There are two points the board fails to consider. One is that by the time the cord’s tightness was tested Forrestal had no pulse or muscle tone, and his body had lost a massive amount of blood from the eviscerating damage of a 13 story fall. Doubtless all this had the effect of loosening the cord. The second point is that there is another vital process to consider besides breathing: blood flow to the brain. Preventing it requires much less force than choking. The “guillotine” blood choke used in hand-to-hand combat causes unconsciousness in a matter of seconds by compressing the carotid artery.

Neither the NCIS (Naval Criminal Investigative Service, also known simply as the NIS, Naval Investigative Service) nor the FBI is mentioned in the report.

The report insinuates, though no one actually says it outright, that Forrestal momentarily hung outside the window before falling to his death. How far from the building wall was his body found? This important question is never asked.

The name of Edward William Prise is consistently misspelled “Price” throughout the report though actually it is “Prise,” as can be seen from his signature in the Nurse’s Notes.

When Harrison, the watch on duty the night of May 21st, is asked if he heard any unusual noises from the kitchen, he replies not only “No” he adds “I heard nothing.” When asked if he was close enough to hear any unusual noises, he replies not only “Yes” he adds “I definitely would have.” Yet an unusual noise needn’t be loud, and loud or not could be mistaken for a usual noise. His No and Yes are reasonable, his emphasis perhaps peculiar and unjustified. The saying comes to mind: he doth protest too much.

Brought out in later testimony is that the Petridish-cum-ashtray in Forrestal’s bedroom was whole when Forrestal was last seen alive and in shards immediately after his death. (To be precise, the dish/ashtray was gone and broken glass was on the bed.) This shattering of glass was one noise both loud and unusual that Harrison must have heard if he was attentive and not hard of hearing. The board didn’t recall Harrison and ask him about noise from the bedroom as well as from the kitchen. Why did the board confine their question to the kitchen in the first place? What were the sounds, if any, from the bedroom?

Why didn’t the board reexamine Price/Prise after his volunteered testimony about a book and writing, and ask him what he was talking about?

The board fails to ask Utz to clarify the contradiction between his (rather illiterate) testimony that he did not see Forrestal when asked to get orange juice for him, and his later testimony that he did. (Utz doesn’t seem to be precise-minded and may have taken “see” to mean “have some sort of dealing with.”)

The psychiatrist Raines refers to a handwritten copy of a poem Forrestal was supposed to have made. The board doesn’t follow up on this, either during Raines’ testimony or later. A photostat of a handwritten poem appears in the appendix , yet the recorder never particularly introduces it in evidence. It isn’t listed in the exhibits contents. However from Raines testimony you find that it was placed in the nursing record, an odd place for an ancient Greek poem, or any poem for that matter. The nursing record is exhibit 3. Amazingly, no witness is called to determine the poem copy’s provenance or to corroborate Raines’ statement that the handwriting looks like Forrestal’s. (In fact the handwriting is not Forrestal’s, see the next section below, “The World Outside the Report.”)

Why is the book that is implied in Raines’ testimony not among the exhibits?

One gets the impression that Forrestal’s admission to the hospital was voluntary but that there was an element of coercion to his extended stay. As the saying goes: “Possession is nine-tenths of the law” – and they certainly had Forrestal. This was during a period in America when psychiatrists wielded enormous power over someone they labeled “patient.” Just how voluntary was Forrestal’s stay?

When a witness worries, between the lines, about being charged with negligence, it underlines the idea that Forrestal’s death was suicide. Some witnesses might have acted worried for that very reason, though doubtless for most witnesses the worry was sincere (even if to himself he thought it was murder). The same applies to a board member worrying about the Medical Corps being charged with negligence.

Forrestal was in the hospital seven weeks and pretty much well for most of that time, yet nowhere does anyone mention him going much beyond his 16th floor suite – until he went out the window. Why isn’t how he was shut-up in the hospital tower addressed in the report? Was he taken down for a walk outside now and then? (The answer to the second question is No, see the next section.)

Forrestal was restless, pacing the floor, the evening before his death. The report insinuates – this is one of the most insinuatingist reports ever – that the restlessness was due to some dark psychic problem, that even then he was driving himself to self-destruction. But of course his restlessness could have been due to any number of things, and considering his normality, even cheerfulness, at the time, - something else was far more likely – not least of which was that he was anticipating his release. (Again going outside the report, Forrestal’s brother was coming the next day to move him to more congenial surroundings in which to complete his convalescence. If Raines or other witnesses knew of this they didn’t mention it before the board, or if they did mention it it was left out of the report.)

Who were Forrestal’s visitors, especially in the days before his death? Why were none of them called to describe what they and Forrestal had talked about, Forrestal’s mental attitude, his plans for the future?

Forrestal didn’t belong in a hospital in the first place, at least not for an extended stay. He had no medical, organic problem.

The mentality of the psychiatrist Raines is best illustrated by an old anecdote which is not really a joke. A man goes to a psychiatrist and tells him his problem. The psychiatrist pronounces: “You don’t love your mother.” The man replies: “But I do love my mother.” The psychiatrist, triumphantly: “Ah ha! You love your mother too much!” Everyone says Forrestal was doing well before he jumped/got shoved out the window. This is no problem for Raines, who glibly pontificates: When the “patient” is almost cured that is the most dangerous time!

Maybe even Raines didn’t believe it. He was in charge of Forrestal’s case yet he left town for a conference in Canada just days before Forrestal’s death. But the contradiction is nothing for a glib man. Raines says leaving was part of the treatment to wean Forrestal from his “dependence” on him. A dependence not the least in evidence.

Forrestal left no suicide note, but psychiatrist Raines has a ready line of argument. From the missing note and the assumption of suicide he deduces that Forrestal was “impulsive,” then uses that impulsiveness to explain the suicide. The board accepts this circular argument without comment. On reexamination another day, Raines admits – not realizing that it is an admission: “There was nothing in his previous history or behavior to indicate that there would be such an impulsive move ... .” Again and again, the very fact that Forrestal showed no sign of being suicidal is used to insinuate that he committed suicide.

Forrestal was wearing only his pajamas when found on the ledge/roof. Nurse Dorothy Turner searched Forrestal’s room right after she realized the man she had seen outside might be Forrestal and she did not see a bathrobe. Presumably it was in the closet (a shallow closet set in an exterior wall left of the bed) with the closet door closed, as in exhibit 2K, but minus its sash/cord. Why would a man supposedly acting “impulsively” be so fastidious after acquiring the makings of a noose?

Raymond W. Waggoner had no direct knowledge of the case whatever – all he knew was what he read in the newspapers and heard on the radio. Thus it was grossly improper for the board to allow Raines to read Waggoner’s letter as testimony and for the recorder to offer it in evidence. Yet there it went, to be reflected again in the news, like the squeal of a public address system when the microphone gets too near the loudspeaker.

All who saw Forrestal’s body before it was moved from the point of impact refer to the location, if they refer to it at all, as a ledge. When they mention a floor they say it is off the 3rd floor. Board members, however, when initiating discussion of the landing location always refer to a roof. No witness contradicts them. The roof is said to be that of a building two stories high adjoining the central building, and the ledge/roof is said to be level with the central building’s 3rd floor. The board in its two Finding of Facts refers to a ledge rather than a roof . The pathologist testifies that Forrestal’s injuries were “apparently caused by a high fall on a hard surface which was covered with asphalt and cinder rock.” which would indicate he landed on a roof. The one photographer who testified doesn’t say exactly where Forrestal’s body was located but does mention a ledge in a photograph and “Right below that ledge was a roof ... .”

On the first day of the Proceedings the board notes (deck is jargon for floor): “... the body landed on the roof of the second deck, on a level with the third deck, striking first a ledge of the fourth deck ... .” (emphasis added) This is the only place in the report where it is said Forrestal hit something else before landing. No witness mentions this mid-drop strike, though nurse Turner mentions hearing a “double thud.” Does the fourth floor have a ledge?

Here is a more complete quote of the board’s statement referred to above (again emphasis added): “... the body landed on the roof of the second deck, on a level with the third deck, striking first a ledge of the fourth deck on the northeast corner of building one ...” – that is, the central tower. “Corner” is a bit ambiguous on first reading and without knowing the shape of the building. Going beyond the confines of the report for a moment, between the third (maybe fourth) and sixteenth floors the floor plan of the building is shaped like a (very fat) plus sign. Thus each quadrant of the building has one inward “corner” and two outward corners. (See the photographs at the bottom of this webpage, after the report.) The board must have meant the inward corner because they said “the” rather than “a” corner, and because in the time it took Forrestal to drop 13 floors – about 3 seconds – to reach the outward corner directly ahead his horizontal speed exiting the window would have to have been about 20 feet per second.

The board asks psychiatrist Smith, in effect, what he thought of placing Forrestal on an upper floor where he might be in a position to fall or jump. His answer is, in effect, that it’s done all the time. This is patently disingenuous, as is the board’s failure to respond. Since it was Raines who placed Forrestal on the 16th floor, why was a similar question not asked of him? (More on this in the next section below, “The World Outside the Report.”)

Raines’ initial portrait of Forrestal is at times rather unattractive. He may have asked Forrestal leading questions. Though Raines’ unreliability, even mendacity, as a witness is evident, still some of this portrait might be true to life. Keep in mind this is the late 1940s, the heyday of psychoanalysis, a certain kind of psychoanalysis now mercifully in disrepute. People were a little spoiled back then, and Forrestal may have imbibed the prevailing silliness: a self-absorption in nonsense that only the well-off can afford to indulge.

Those are some thoughts that might occur to you if all you knew about the case came from the Willcutts Report.

The World Outside the Report

The following exchange occurs in Raines’ testimony of May 24:

Q.Captain Raines, I show you a clinical record, can you identify it?

A.This is the nursing record of Mister Forrestal. The only portion I don’t recognize is this poem copied on brown paper. Is that the one he copied? It looks like his handwriting. This is the record of Mister Forrestal, the clinical record.

The reference the one shows that the existence of the poem was common knowledge. Later regarding Forrestal, Raines refers to

... the complete absence of any suicidal note or expression of suicidal intent in any way. He left no message at all except this poem which I am sure was meant for me and was not a portion of the suicide. That is to say, I think he was simply writing that out to demonstrate how badly he felt. People who contemplate suicide almost invariably leave some note to someone and usually someone close.

Not the most consistent thing you may have read. Nor was Forrestal close to Raines. In any case that’s it, neither Raines nor the board have anything further to say about what is – in a wishy-washy way – claimed to be a substitute for a suicide note!

And both Raines and the board must have known what was going on in the world outside the hospital that made the poem especially significant.

The poem consisted of some verses from Sophocles’ play Ajax. Spoken by a Greek chorus, the sentiment is rather like Hamlet’s in his soliloquy on death. Right from the beginning the press played up this poem. A New York Times article featured it in an article on May 23. This was the day before Raines testified, so someone on the board or within the hospital must have talked about it. It was this poem, and the rumor either made up or repeated by unscrupulous journalists that Forrestal decided to kill himself while copying it, that more than anything else gave the notion of suicide semi-plausibility.

And the board let it pass as if it were a minor detail. This is the only place in the report where the poem gets mentioned.

There are two problems with the newspaper stories. First, there is no evidence Forrestal had been copying anything immediately before his death. There were no witnesses at the time. Corpsman Price/Prise went out of his way to say that he wasn’t sure that Forrestal wrote anything earlier that evening, and Harrison said he had not seen Forrestal reading while he was on watch after midnight. (The account by Arnold A. Rogow in his 1963 biography of Forrestal is a complete fabrication. Rogow invents the actions of Price/Prise, the number of copied lines of the poem and many other things.)

The other problem with the news story – and with Raines’ testimony – is that the poem copy is not Forrestal’s. The handwriting of the poem differs so markedly from Forrestal’s that proof requires nothing further than “Behold!”

Note fromJames Forrestal to John O’Hara

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Note fromJames Forrestal to Harry Truman

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Willcutts Reportpoem transcription

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Aside from the holistic difference – Forrestal’s handwriting would never be described as smooth like that of whoever did copy the poem – differences in detail include: 1. Slant: slight to the left vs. pronounced to the right; 2. o: typically open vs. closed; 3. s–internal to word: rounded loop at end vs. usually no loop and cusped when present; 4. t–end of word: usually a separate cross vs. always integrated cross; 5. r–upper left: simple square corner vs. typically pronounced rise; 6. p–upper left: no rise vs. pronounced rise; 7. m, n: written almost like w, u with cusps at top vs. conventional way; 8. I–left: open vs. closed; etc. Someone besides Forrestal wrote out the Ajax verses, and it is obvious.

Raines claimed this poem was written in Forrestal’s handwriting when obviously it isn’t. Either Raines is a complete fool – and there is some evidence for that – or this was not an honest mistake. No wonder the Navy didn’t release the report.

To repeat, the board never follows up on the poem. We are not told where it was found, who found it or anything about a book from which it might have been copied. Why did the board not make the poem a separate exhibit and investigate it thoroughly? Who was responsible for sticking it in the nursing record, of all places? Raines probably lied, but what of the board members? They could not have honestly omitted a systematic examination of the poem and its provenance, mere incompetence doesn’t cover it.

(Exhibit 3 is the nursing or clinical record. The Appendix contains many photostats for this exhibit and most have handwritten numbers at the bottom, in order. The first photostat is the only one containing a poem. It shows the title and the poem’s first 15 lines – or 7½ depending on how you count – except for the last word of the bottom line – or midline – where the corner is torn off. The photostat is obviously slightly truncated from the original, slightly assuming the original was 8½ by 11. The photostat is unnumbered but in the photostat after it, the items – there are two in the second photostat – are numbered 2 and 3. Evidently the one photostat of the poem shows all the board had of any poem though it would take three more lines to complete its last sentence.)

Note Raines’ remark that the poem is written on brown paper, as if that were as unusual as it sounds. Did Forrestal even have access to brown paper instead of white? Yet another item in the board’s capacious blind spot.

Note the poem copier’s clean, self-confident manner of writing. Yet we are to believe that seconds later, in an access of impulsivity, he will grab his bathrobe sash, go across the hall and through the kitchen, tie one end of the bathrobe sash to the kitchen radiator below the window – not too well – tie the other end about his neck with a jerk, and clamber over the window sill (measuring about two feet deep) expecting to hang outside by what’s left over. Because Drew Pearson said he was crazy?

Note the moldered look of the paper on which the poem is written. It is creased and ragged, the lower right corner torn off, as if it had been knocking about for quite awhile. Why wasn’t this lack of freshness remarked upon and inquired about?

The poem invites conjecture. The most telling fact is this: Whoever copied the poem made no attempt whatever to imitate Forrestal’s handwriting. This suggests the copy was made innocently, that it was never intended to be taken for Forrestal’s. It could have been made long before Forrestal even arrived at Bethesda.

If there was an anthology of poetry in Forrestal’s room containing “Chorus from Ajax” it probably would have come from a library. Someone else, another patient say, might have made a copy of the poem and left it in the book, quite awhile ago judging from the scruffy, knocked about look of it, and eventually it found its way into Forrestal’s room along with the book. Or the poem’s copier could have placed it in another book that Forrestal eventually got, which would explain the lack of any book in the exhibits since in that case Forrestal’s room would not have contained the original book. (Both conjectures assume the poem was found in Forrestal’s room as the report insinuates.)

But one needn’t determine the how or who of the poem to know that it played no rôle in Forrestal’s life, and only the dishonesty of Raines, the Willcutts board, and certain journalists and biographers have given it one in his death.

An honest attempt at biography is the book The Death of James Forrestal by “Cornell Simpson,” a penname, published in 1966 (unchanged, the author relates, from a manuscript written five years earlier) and to date the best work on the subject of Forrestal’s death. The book emphasizes the possibility that Forrestal was murdered by Communist rather than Zionist agents.

Simpson describes an interview with Forrestal’s brother Henry, at his home in Beacon, New York. Henry Forrestal said that the hospital refused to allow at least three of Forrestal’s close personal friends to visit and at first refused him as well. This gives the lie to the insufferable Raines insinuating that only cranks and gold diggers were refused admittance and saying outright that Forrestal’s friends gave Raines “nothing but the most complete cooperation.” From the book:

Henry Forrestal tried several times to see his brother in the hospital but was refused visiting rights by both Dr. Raines and [acting commanding officer of the hospital] Captain Hogan. He finally managed to see his brother briefly after he had informed Hogan that he intended to go to the newspapers and after he had threatened legal action against the hospital.

... when he was finally allowed to see his brother, he found James “acting and talking as sanely and intelligently as any man I’ve ever known.”

......................................

Finally, he decided to take his brother into the country to complete his convalescence. Henry Forrestal made train reservations to return to Washington on Sunday, May 22, and reserved a room at the Mayflower Hotel for that day. He then phoned the hospital and told them he was arriving to take his brother.But only hours before Henry Forrestal was due to board his train, he received the news that his brother was dead.

......................................

... Henry Forrestal stated ... that James Forrestal positively did not kill himself. He said his brother was the last person in the world who would have committed suicide and that he had no reason for taking his life. When [Henry] Forrestal talked to his brother at the hospital, James was having a good time planning the things he would do following his discharge. Henry Forrestal recalled that ... the hospital officials admitted that he would have been released soon. To Henry Forrestal, the whole affair smelled to high heaven. He remarked about his brother’s treatment at the hospital, his virtual imprisonment and the censorship of his visitors. ...He was bitter when recounting that from the first minute[,] the officials had insisted the death was a result of suicide; that they did not even consider the possibility of murder even though there was no suicide note, though his brother acted perfectly normal when the corpsman [Utz] saw him only a few minutes before his death ... ....Then he repeated his belief that James Forrestal did not kill himself; that he was murdered; that someone strangled him and threw him out the window.

Simpson’s book was favorably reviewed by Medford Evans in American Opinion April 1967. Evans had been living in Washington D.C. at the time of Forrestal’s death. From his review:

I remember being convinced immediately that he had not committed suicide—which was the official story—but had been murdered. My reason was simple, but for myself, conclusive. The first report I read, in the Washington Post, said that Forrestal’s body had been found on the hospital roof below the open sixteenth-story window of the tower, clad in pajamas and robe, with the bathrobe cord knotted about his neck. The theory was, said the Post, that he had hanged himself out the window, and then the cord had slipped from the radiator or whatever it was tied to inside the window.I didn’t believe it. I believe that men hang themselves, or that they jump out sixteenth-story windows. But I don’t believe that they hang themselves out sixteenth-story windows.On the other hand, it is no trouble at all to imagine a murderer in orderly’s habit garroting a man with his own bathrobe cord, then heaving him out the window—perhaps with semi-maniacal haste and strength on hearing or thinking he heard approaching footsteps.

The biography Driven Patriot: The Life and Times of James Forrestal by Townsend Hoopes and Douglas Brinkley (1992) is flawed by references to Rogow’s dishonest biography, but the book contains some valuable material. Note this item, which contradicts Smith’s testimony mentioned in the section above:

In 1984, Dr. Robert P. Nenno, a young assistant to Dr. Raines from 1952 to 1959, disclosed that Raines had been instructed by “the people downtown” to put Forrestal in the VIP suite on the sixteenth floor of the hospital. ... The decision to put Forrestal in the tower suite was regarded by the psychiatric staff as “extraordinary” for a patient who was “seriously depressed and potentially suicidal,” especially when the hospital possessed two one-story buildings directly adjacent to the main structure that were specifically organized and staffed to handle mentally disturbed patients.

Unfortunately we aren’t told what floors had VIP suites. Perhaps there were none on the ground floor, even that they were confined to the 16th floor, in which case the fact that people at the White House or “the people downtown” told Raines to put Forrestal on the 16th floor is merely a consequence of asking for a VIP suite, which is not by itself suspicious (though that Forrestal was taken to Bethesda in the first place is). In any case the above shows that Smith lied when he said, in effect, that there was nothing at all odd about placing Forrestal on the 16th floor. It also suggests that Raines knew how to keep quiet before a board of inquiry.

Forrestal’s chauffeur was a Navy enlisted man named John Spalding. Living in Littlestown, Pennsylvania, in 2008 at the age of 87 he revealed in a recorded interview (“Handwriting Tells Dark Tale?” by Hugh Turley, Hyattsville Life & Times December 2008) how the Navy treated him right after Forrestal’s death. He was called into the office of Rear Admiral Monroe Kelly. “He had a big map and he said where do you want to go for duty … You are going to leave tonight.” Mr. Spalding decided on the base at Guantánamo, Cuba. (In 1949 Havana was a famous vacation spot, so this is not as strange as it would be today.) Monroe Kelly and his aide Lieutenant James A. Hooper made him sign a statement swearing that he would never speak to anyone again about Forrestal. Also in the interview Mr. Spalding said that Forrestal had never appeared depressed, paranoid or in any way abnormal in his presence. Another witness absent from the proceedings.

There’s much more about the world outside the Willcutts Report, including suspects and motivation, under the link “David Martin” near the top of this webpage.

Material Missing in the Copy of the Report and/or the Report Itself

Some exhibits are missing from the Appendix in the FOIA copy of the report provided by the Navy:

Exhibit 4 – a description of the bathrobe cord, see testimony of Willie Ray Barnett.

Exhibits 5A, 5B – two pre-autopsy photographs, see testimony of William M. Silliphant.

The Navy withheld these exhibits on purpose. Exhibit 4 may have been withheld thinking it was a pre-autopsy photo. The Navy’s transmittal letter to David Martin (from P. A. Leonard, Department of the Navy, Office of the Judge Advocate General, dated April 6, 2004) said:

Please be advised that exhibit 1, photographs of Mr. Forrestal’s body, exhibit 4, and exhibit 5, photographs of Mr. Forrestal’s injuries, were not included in our copy of the investigative report ...

And goes on to claim (erroneously if tastefully) this was because of privacy issues. However the investigation’s recorder refers to exhibit 4 not as a photograph of the body but as a “description of the cord” (see photocopy page 64). By the way, when referring to the cord one witness uses the word “sash,” all others use “cord,” never “belt.”

The missing description of the cord is a major lapse since there is little description of it in the report. And if any of the missing photographs reveal the distance of Forrestal’s body from the building wall, that would provide information lacking in the report.

The exhibit photographs 2A through 2K by John Edward McClain were obviously taken several hours into daylight, yet presumably some photographs were taken earlier, say about the same time as Harley F. Cope photographed the body (between 3 and 3:15 a.m.). If so, these photographs are missing from the report.

Then there are two, possibly three or four, unacknowledged gaps in the text of the report. The transcript of Francis Whitney Westneat’s testimony is missing several lines involving what was found on Forrestal’s body (see the top of photocopy page 68). This lapse may be due to faulty photocopying by the Navy.

In the transcript of Dorothy Turner’s testimony, which also appears typographically sound, the board asks (emphasis added): “You said you saw his slippers and a razor blade beside them; where did you see them?” Yet there is no record of Dorothy Turner or anyone else mentioning slippers before this. She does, however, answer the question as if she had. Very likely there is a gap in the original report. See photocopy page 80, question 5.

The transcript of Edward William Price/Prise’s testimony, though it appears typographically sound, may be missing a part involving “writing” and an unnamed and possibly nonexistent “book,” both of which he referred to in the statement he volunteered after questioning. Even if this writing and book were common knowledge from discussion among hospital staff or reading newspaper reports outside the courtroom – and that does appear to be the case (see the section immediately above) – the board, one would think, would have asked him to be complete and specific for the official record. Thus there may be a gap in the original report. Another possibility is that the board’s failure to reexamine Price/Prise is part of the cover-up of the alleged suicide poem: if there is no book and no writing, the poem would have to be examined more closely. See photocopy page 75.

Finally, consider the last page, photocopy page 89, the review of evidence headed “Office of the Medical Officer in Command” and dated June 1, 1949. A page might be missing after it since it ends so abruptly and also one would expect it to be signed by Admiral Willcutts.

Obscured Witness I

One witness, Edward William Prise, has his unusual surname, a British variant of “prize” and the root of “surprise” (sur·prize = over·take), misspelled throughout the report as Price. You can determine that it is Prise from his signature on a phone reception note and on the “watch assumed” and “watch relieved” entries of various Nurse’s Notes in the exhibits. (Also he was wounded in Korea a year or so later and the military’s typed casualty report of October 9, 1950 reads “Prise.”) During the proceedings he says his surname twice, Robert Wayne Harrison says it once and Regina M. L. Harty three times. If he pronounced it price the misspelling might have been a mistake, if prize almost certainly it was intentional.

Obscured Witness II

Another witness, nurse Hardy, has her name misspelled throughout the report as Harty. Furthermore, unlike other witnesses, her name is never given in full. Among fellow workers she used the name Margie (a nickname for Margaret, Margret or Marjorie, presumably one of her middle names), but in her testimony – according to the report – she gives her name as Regina M. L. Harty. During the proceedings the following witnesses say her name: herself, Robert Reynolds Deen and Dorothy Turner. (The fact that her name was Hardy rather than Harty and that she was called Margie, is from the late Connie Riggs, a nurse at the time of Forrestal’s death stationed at Quantico who knew some of the nurses stationed at Bethesda, including Margie Hardy. The two exchanged Christmas cards for several years, so there is no question Ms. Riggs had the correct name.) Because the name Harty is pronounced differently from Hardy and because Harty is an unusual name and Hardy a common one, and considering that how Americans tend to slur their speech any confusion would go in the direction of Hardy rather than Harty, almost certainly the people responsible for the report misspelled the name on purpose.

Missing Witnesses

24 hours a day in three shifts at least one medical corpsman was with Forrestal in his hospital suite or at the nurse’s desk right outside the door. By the time Forrestal disappeared a total of six corpsmen had been on watch, but you would never know it from the body of the Willcutts Report. The board called only two of them to testify, Price/Prise and Harrison.

Undoubtedly these two were important, Harrison being the man on watch when Forrestal disappeared and Price/Prise the man on watch only two hours before. However, the board was investigating the suspicious death of a man entrusted to their care, a man who happened to be the former U. S. Secretary of Defense. His death was due to either suicide or murder, and you would expect its investigators to put an appropriate amount of effort into determining which.

One of the four uncalled corpsmen was W. R. Breon. He attended to Forrestal once a day throughout his stay for a total of 52 shifts – over 410 hours give or take a few – more than any other corpsman. Surely he was worth questioning as to Forrestal’s moods and habits.

Another unmentioned corpsman was J. M. Kelley. He worked 31 shifts during the first three fifths of Forrestal’s stay.

The non-witness C. F. Suthers worked 17 shifts near the end. Though he was with Forrestal fewer hours than Breon, Price/Prise and Kelley he is the board’s most glaring omission. He had worked the regular third shift before Harrison replaced him only the day before Forrestal disappeared. Of all the corpsmen, Suthers would have been best able to testify about Forrestal’s moods and habits during those hours of the day.

The fourth man the board ignored was Iver P. Kipp, who worked three shifts near the beginning of Forrestal’s stay. Together Breon, Kelley and Kipp were the corpsmen on watch during Forrestal’s first days at Bethesda. They were in a position to tell the board, and have it preserved in the record, about his general health when he arrived.

Besides the four hospital corpsmen, none of Forrestal’s visitors were called to testify. For example, Admiral Swanson, head of the medical corps, visited 14 times times throughout Forrestal’s stay. According to Dr. Hightower’s testimony, question 14, Forrestal’s financial administrator and close friend Paul Strieffler visited Forrestal Saturday morning May 21, the day before he died. How did Forrestal strike Striefler at that time and did Forrestal mention any changes to his finances suggesting that he was, or was not, looking forward to a future?

Instead, the testimony as to Forrestal’s state of mind is limited to hospital personnel: the psychiatric doctors (strangers, even professional psychiatrists – perhaps and ironically especially psychiatrists – are less than trustworthy judges about this), Price/Prise and a man who had been with him only one shift and a fraction of the last, Harrison.

Finally, the board failed to interview any of the other patients who were on Forrestal’s floor at the time of his death.

Many of the missing witnesses, though none of the floor’s other patients, can be found buried in the (incomplete) handwritten Nurse’s Notes contained in the Report’s appendix of exhibits. Buried is no exaggeration. It takes a great deal of effort and perseverance to make sense of these notes in their original photocopy/photostat form. They are now cleaned up in “The Nurse’s Notes” linked to in the Exhibits section.

Editorial Protocol

Information in the original Willcutts Report comes in several forms: typewriter printing, letterhead printing, letterhead logos, stamped printing, and handwriting. In this HTML version typing is reproduced in courier font, letterhead printing in arial font. A logo is replaced by a brief description of the logo within square brackets. Stamped printing is placed within square brackets and indicated as stamped. Handwriting is reproduced in italicized cursive font. For example:

xyz

– typed text.

xyz

– letterhead.

[logo: description of logo]

– logo.

[stamp:xyz]

– stamp.

xyz

– handwriting, no distinction between longhand and printing.

Other than logos and stamps, square brackets contain comments not in the original document. Such comments are limited to pointing out illegible or apparently missing text and misspellings – all such misspellings being reproduced as in the original document. Since “alright” always appears instead of “all right” in the original document “sic” has not been inserted. Incorrect grammar also remains unnoted. Page numbers have been added atop each page in square brackets. (Increase this number by nine to obtain the page number of the Seeley G. Mudd Manuscript Library’s PDF file.) The lowercase L used for the digit one on old typewriters has been silently replaced by the digit one. Most end of line carriage returns and all word continuation hyphens have been silently omitted. For readability upright quote-marks and apostrophes have been replaced with slanted ones. Typographical corrections written on the original have been silently followed. Where a space was obviously intended in compacted text it has been silently restored when that would make the text significantly clearer but otherwise usually left alone (for example: U.S.Navy), and similarly for an extraneous space. Indent widths, margins and centering may differ somewhat from the original.

Introduction Continued

The landlubberly reader may be surprised to find how frequently nautical terminology appears in the report, indeed the hospital building is spoken about as if it were a battleship. Floors are decks, left and right are port and starboard, the kitchen is the galley; and then there is swab, chow, the head. Instead of being inside the building one is aboard.

Two terms used in a military board of inquiry may be unfamiliar to the reader: the “recorder” is the prosecutor, here beholden to the Medical Corps; the “reporter,” on the other hand, records the proceedings and testimony.

Tower eight, tower twelve, etc. indicate the floor of the single tower.

One final observation: The less educated and lower ranked a witness the more perceptive and connected to reality they seem to be. When a glib head psychiatrist says, after the fact, that the period just before recovery, when a “patient” is almost completely well, is the most dangerous – it sounds manufactured to suit the occasion. When a nurse or corpsman says a man was friendly and cheerful, and there was nothing unusual about this – it sounds authentic.

One needn’t agree with everything James Forrestal did or believed during his career to care about his death and the veracity of his last associates. Involved is the possible assassination of someone who had been one of the highest ranking officials in Washington, and a subsequent cover-up – as argued above – which was, it could be argued, even worse. Only in a banana republic are such things treated lightly.

Here then is the Willcutts Report. To make searching easier the entire report is on this one webpage, except that links are provided to the exhibits in the appendix. You can just scroll down or else click on one of the following – which are our descriptive titles, not necessarily in the report itself – to go right to a particular section. Use your browser’s back button or press the Backspace key or Alt left-arrow keys to return here.

The proceedings of the board of investigation, the proceedings and findings of the board of investigation in revision, and the actions of the convening and reviewing authorities thereon in the attached case of the late Mr. James V. Forrestal, are approved.

I, Winfred Overholser, of Washington, D. C., being duly sworn, do hereby solemnly state as follows: I am a physician, and received the degree of Doctor of Medicine from Boston University in 1916. During my entire professional career since that time I have specialized in the care and treatment of mental disorders. I served in the Neuropsychiatric Section of the Army in 1918-19, and in the Massachusetts State Hospital Service from 1917 to 1936. From June 1934 to December 1936 I was Commissioner of Mental Diseases for the Commonwealth of Massachusetts. Since October 1937 I have been Superintendent of Saint Elizabeths Hospital, Washington, D. C., a large mental hospital operated by the Federal Government. From 1925 to 1934 I taught psychiatry at Boston University School of Medicine, and since 1938 I have been Professor of Psychiatry at George Washington University School of Medicine. I am a former President of the Massachusetts Psychiatric Society, the New England Society of Psychiatry, and the American Psychiatric Association. I am also a member of the National Board of Medical Examiners. From 1940 to 1945 I was Chairman of the Committee on Neuropsychiatry of the National Research Council and Consultant to the Office of Scientific Research and Development. I am duly licensed to practice medicine in Massachusetts and the District of Columbia.

I have read carefully the report of the very thorough inquiry conducted by a Board of Investigation convened at the United States Naval Hospital, Bethesda, Maryland, on May 23, 1949 to investigate and report upon the circumstances attending the death of Mr. James V. Forrestal at that hospital on May 22, 1949.

From a study of the report, it is my opinion that Mr. James V. Forrestal came to his death by suicide while in a state of mental depression. It is my further opinion that the care

and treatment given to Mr. Forrestal during his stay at the Naval Hospital were entirely in accord with modern psychiatric principles, and that his death was not due to the negligence, fault, intent, or inefficiency of any of the physicians, nurses, or ward personnel concerned in his care.

Winfred Overholser, M.D.

Subscribed and sworn at Washington, District of Columbia, this 19th day of September, 1949, before me,

Dear Sir: The proceedings and findings of the board of investigation in the case of the late Mister James V. Forrestal, with accompanying exhibits, were delivered to me by Lt. Comdr. Kelly this morning. In our telephone conversation yesterday you asked me to study this material and to express my professional opinion on two essential points of psychiatric principle and practice involved. The first question: In general, in the care and treatment of a depressed patient with suicidal potentialities who is showing indications of recovery, is it proper psychiatric practice to increase the range of the patient’s activities and to decrease the restrictions and supervision? The answer to this question is definitely, “Yes.” Not only is this a permissible and humane way of dealing with a sensitive person, but there are clinical conditions in which the maintenance of unduly tight

restrictions may seriously hinder the patient’s recovery. The second question was concerned with the applicability of these general principles to this particular case;-whether the condition and progress of Mister Forrestal, as a patient, justified the relaxation of strict surveillance which apparently made possible his successful suicidal act. Because I have not had the clinical advantage of personal examination of this patient, which is of course the most reliable basis for clinical judgment, I have examined the proceedings of the board of investigation with great care, including the accompanying nursing notes. It is clear that there was no tangible fault of hospital care nor neglect of orders, responsible for his suicide, and the issue is clearly whether Dr. George N. Raines, as the responsible psychiatrist in charge of the patient’s care, had exercised proper psychiatric judgment in his decisions as to orders which involved the taking of calculated risks. The facts gathered in the board’s investigation indicate adequately that careful and proper judgment was exercised, and that Dr. Raines’ decisions were sensible and proper.

In this connection it is appropriate to point out that a contrary line of treatment, involving a continuance of very sharp restriction and supervision, would also have involved the taking of risks,-especially risks of the patient’s developing and establishing a settled pattern of self-distrust and self-depreciation, to which depressed patients are particularly liable, and which may deepen and prolong the depression. Furthermore, even the strictest nursing restrictions and supervision cannot completely guarantee against suicide, particularly if a keen-minded and quick-acting person like Mister Forrestal is made antagonistic by irksome limitations at a time when his range of interests is increasing. There are risks, therefore, of one kind or another, in the making of every such decision. In the case of so distinguished a person as Mister Forrestal, there would have been much incentive to follow the more conservative, restrictive regime. Dr. Raines’ decisions displayed courage in the application of psychiatric principles to provide the best chances for good recovery. For this he should be commended.

I, Edward A. Strecker, having been duly sworn, do depose and say: That I received my degree, of Doctor of Medicine, from Jefferson Medical College in Philadelphia in 1911; that I have been engaged in the study and practice of psychiatry exclusively since 1913, including service in France in World War I, as Divisional Psychiatrist to the 28th Division; that I am a Diplomate of the American Board of Psychiatry and Neurology, Inc. and a former Member of the Board and ex-President; that I have occupied various important psychiatric positions in the past, including Professorship of Mental and Nervous Diseases, Jefferson Medical College, Philadelphia, and Professor of Psychiatry and Mental Hygiene, Yale University; that I am a member and a former President of the American Psychiatric Association, and a member and former Vice-President of the American Neurological Association, and a member of many scientific and learned societies in the United States and abroad, including the Royal Medico-Psychological Association of Great Britain; that I am the author of a number of books and many treatises pertaining to the subject of psychiatry; that my important present positions are Professor of Psychiatry and Chairman of the Department, School of Medicine, University of Pennsylvania; Professor of Psychiatry, Graduate School of Medicine, University of Pennsylvania; Consultant and Chief-of-Service, Institute of the Pennsylvania Hospital, and many other positions.

2. I further depose and say that I have carefully examined the proceedings and findings of the Board of Investigation in the case of the late Mr. James V. Forrestal. Included in the examination of these documents there was the testimony of the various physicians who attended and were in contact with Mr. Forrestal, the testimony of Dr. William C. Menninger, the corpsmen, all the medical and nursing records, the letters, the photographs and, in fact, all the documentary exhibits pertaining to this case.3. My considered opinion is in complete accord with “The Finding of Facts”. These constitute the final opinion of the Board of Investigation and concern (1) The identification of the body of Mr. James V. Forrestal; (2) The approximate date of the death of Mr. Forrestal and the medical cause of death; (3) The review of the behavior of the deceased during his residence in the Bethesda Naval Hospital, and the diagnosis of his mental condition as “mental depression”; (4) The review of the treatment and precautions in the treatment of Mr. Forrestal, and an opinion that “they were within the area of accepted psychiatric practice and commensurate with the evident status of the patient at all times”; (5) That in no manner was the death of Mr. Forrestal due to “intent, fault, negligence or inefficiency of any person or persons in the Naval Service or connected therewith”.

Board of Investigation Convened at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland, on 23 May 1949 to Investigate and Report Upon the Circumstances Attending the Death of Mr. James V. Forrestal at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

1. The record of proceedings of the board of investigation of which you are a senior member, in the case of Mr. James V. Forrestal, is herewith returned to the board.

2. Attention is invited to the enclosures wherein it is recommended that the board be reconvened for the purpose of further deliberation with a view of fixing the time of Mr. Forrestal’s death as definitely as possible.

3. The board will reconvene for the purpose stated in the preceding paragraph. At the conclusion of the proceedings in revision, the record will be returned to the convening authority.

The Board of Investigation reconvened by direction of the convening authority for the purpose of further deliberation with a view of fixing the time of Mr. Forrestal’s death as definitely as possible.

The board reviewed its original report and the endorsements thereon.

In review of the findings of the board it was evident that the phraseology of the first line of paragraph two under the Finding of Facts stating “that the late James V. Forrestal died on or about May 22, 1949” was not an exact statement of the facts determined by the board and therefore in agreement with endorsement five this statement is herewith changed to read “That the late James V. Forrestal died about 1:50 a.m. on Sunday, May 22, 1949.”

2. The Secretary of the Navy is of the opinion that the language in paragraph 2 of the Finding of Facts, dated July 11, 1949, made by the Naval Board of Investigation appointed to inquire into the suicide of the former Secretary of Defense, James Forrestal, is ambiguous and ill advised in the following particulars:

(a) The first line of paragraph 2 under the “Finding of Facts” states, “that the late James V. Forrestal died on or about May 22, 1949.” The record indicates that Mr. Forrestal’s body was found at 1:50 a.m., and that he was pronounced dead at 1:55 a.m. This, taken in connection with the two words “or about” in the language quoted above, would indicate that the Board of Investigation could not determine whether Mr. Forrestal died before midnight or after midnight, and would at least imply that his whereabouts was not known during that period of time, with the possible deduction from such a statement that he may have jumped out of the window before midnight and that fact not have been known to the staff.

3. In view of the above it is recommended that the record be returned to the convening authority for submission to the Board for the purpose of further deliberation with a view of fixing the time of Mr. Forrestal’s death as definitely as possible. For instance, it could be stated he died about 1:50 a.m. on Sunday, May 22, 1949, or whatever would definitely and accurately reflect the fact as found by the Board.

From: The Chief of Naval Personnel.To: The Secretary of the Navy.Via: The Chief of Naval Operations.

Subj:

Board of Investigation – Death of James V. Forrestal, civilian, conv. by MOIC, NatNavMedCtr, Bethesda, Md., (SOP), 22 May 1949.

1. Forwarded, recommending approval of the proceedings and findings of the Board of Investigation in the attached case and the actions of the Convening and Reviewing Authorities thereon, subject to the remarks of the Convening and Reviewing Authorities.

To inquire into and report upon the circumstances attending the death of the late James V. Forrestal,that occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

1. That the body found on the ledge outside of room three eighty-four of building one of the National Naval Medical Center at one-fifty a.m. and pronounced dead at one fifty-five a.m., Sunday, May 22, 1949, was identified as that of the late James V. Forrestal, a patient on the Neuropsychiatric Service of the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

2. That the late James V. Forrestal died on or about May 22, 1949, at the National Naval Medical Center, Bethesda, Maryland, as a result of injuries, multiple, extreme, received incident to a fall from a high point in the tower, building one, National Naval Medical Center, Bethesda, Maryland.

3. That the behavior of the deceased during the period of his stay in the hospital preceding his death was indicative of a mental depression.

4. That the treatment and precautions in the conduct of the case were in agreement with accepted psychiatric practice and commensurate with the evident status of the patient at all times.

5. That the death was not caused in any manner by the intent, fault, negligence or inefficiency of any person or persons in the naval service or connected therewith.

To inquire into and report upon the circumstances attending the death of the late James V. Forrestal,that occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

Record of Proceedingsof aBoard of InvestigationConvened at theNational Naval Medical Center, Bethesda, Maryland,By order ofThe Medical Officer in Command, National Naval Medical Center, Bethesda, MarylandTo inquire into and report upon the circumstances attending the death of the late James V. Forrestalthat occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

A Board of Investigation to inquire into and report upon the circumstances attending the death of Mr. James V. Forrestal.

1. A Board of Investigation consisting of yourself as Senior Member and Captain Vincent Hernandez, MC, U. S. Navy, Captain Harold J. Cokely, MC, U. S. Navy, Commander William W. Ayres, MC, U. S. Navy, and Lieutenant Commander James D. Wharton, MC, U. S. Navy, as recorder, will convene at the U. S. Naval Hospital, National Naval Medical Center Bethesda, Maryland, at the earliest opportunity for the purpose of inquiring into and reporting upon the circumstances attending the death of Mr. James V. Forrestal, which occurred on May 22, 1949, at the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

2. The Board is hereby empowered and directed to administer an oath to each witness attending to testify or depose during the course of the proceedings of the Board of Investigation.

3. The proceedings of the Board will be conducted in accordance with the provisions of Chapter X, Naval Courts and Boards, and a complete Finding of Facts submitted.

4. The attention of the Board is particularly invited to the provisions of sections 731, 732, 733, 734 and 735, Naval Courts and Boards.

The convening order, hereto prefixed, was read, and the board determined upon its procedure and decided to sit with closed doors.

No witnesses not otherwise connected with the investigation were present.The board announced that it would adjourn to the Morgue at the U. S. Naval Medical School, National Naval Medical Center, Bethesda, Maryland, for the purpose of viewing the body.

The members of the board examined the body and identified it as that of the late James V. Forrestal, and recommended that an autopsy be made.

The members of the board then proceeded to Room sixteen eighteen, tower sixteen, building one of the National Naval Medical Center, Bethesda, Maryland, and viewed the room occupied by the late James V. Forrestal and then proceeded to Room sixteen twenty, the galley on tower sixteen of building one of the National Naval Medical Center, Bethesda, Maryland, for the purpose of viewing that room.The members of the board then proceeded to the scene of the landing of the body. It was noted that the body landed on the roof of the second deck, on a level with the third deck, striking first a ledge of the fourth deck on the northeast corner of building one of the National Naval Medical Center, Bethesda, Maryland.

All the members of the board returned to the regular place of meeting where the board was reassembled.

Present: All the members, the recorder, and the reporter.

The board then, at 12:30 p.m., took a recess until 1:30 p.m., at which time it reconvened.

Present: All the members, the recorder, and the reporter.

No witnesses not otherwise connected with the investigation were present.

Examined by the board:6. Q. Can you tell us at what time you arrived on the scene and at what time you took the pictures?

A. Yes, the pictures – that series of pictures were taken between three and three fifteen. The last picture was taken at three fifteen, as a matter of fact.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

3. Q. Were you called upon recently to take pictures concerned with the death of the late James. V. Forrestal?

A. I was asked to shoot a series of pictures of his room, diet kitchen and up and down of the outside of the building.

4. Q. I show you eleven pictures; can you identify them?

A. Yes, sir. This picture was taken from the diet kitchen window shooting down toward the ground, toward this ledge. The camera was held on the outside of the building.

Examined by the board:5. Q. What ledge – the ledge of where?

A. There apparently was an arm extending out several decks below, sir.

6. Q. What floor would that correspond to?

A. The third floor. Right below that ledge was a roof like in proportion to the second floor; bunch of swabs, racks and looks like a screen there. This second picture was taken standing on a chair in the diet kitchen; I believe that is on the sixteenth floor. I had a man with me who pushed the screen back. You can see the upper corner of the screen, upper right hand corner, gives you a black appearance there. The dots were running diagonally across. Upper portion of picture is building, wing in back of this. This is out of focus. We were shooting for finger prints [sic] which we were requested to get and that is what we have, sir. This third picture was taken standing on the deck with the screen, letting the screen of the window come back in place as near as it would of its own accord

which also gave us some fingerprints. The fourth picture is a picture that was shot of the ledge of the third deck. It has identifying marks where it joins into the building. The fifth picture is a picture of a rug with some broken glass on it, taken approximately two feet from the end of the bed. We were unable to get any identifying marks except the rug; couldn’t pick up the bed because the glass wouldn’t show. It was room sixteen eighteen. This is the sixth picture, a picture of the interior of the diet kitchen on the sixteenth floor; we were standing in the hallway shooting into the diet kitchen. That’s all we have, just a picture of that. This is a picture in the bathroom on the sixteenth floor. We set up in the bathrub [sic]; only thing we could use as identifying mark was the bowl; our object was to show this was a special screen with lock that worked with a key, sir. Picture eight was taken on the sixteenth deck in room sixteen eighteen. We took it of the outboard window front showing this screen would only open to that distance, sir. Picture nine was taken from the roof of the third deck shooting straight up to the diet kitchen window showing the height of the tower, and giving windows and the corner. Number ten is a picture of the room on tower sixteen standing in the outboard left hand corner shooting diagonally across it showing the bed and placement of chair. Picture eleven is the picture from the entrance again showing the screen as far as it will open and the arrangement of that side of the room, sir.

Examined by the board continued:

7. Q. You mentioned picture eight showed that the screen could open; was the screen open when you took the picture or did you open it to see how far it would open?

A. The screen was approximately in that position; I believe I did pull on it, sir, but as far as my opening it or unlocking it I just pulled it on back taut.

The eleven pictures were presented by the recorder to the board as an exhibit. There being no objection, they were so received and are appended marked “Exhibits 2A through 2K.”

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

2. Q. Captain Raines, would you state your qualifications as a neuropsychiatrist?

A. I am a diplomate of the American Board of Psychiatry and Neurology, certified in psychiatry nineteen forty and in neurology nineteen forty-one. I am a fellow of the American Psychiatric Association, Chairman of the Committee of Nomenclature and Statistics of the American Psychiatric Association, member American Neurological Association, fellow of American College of Physicians, member of the American Academy of Neurology. I have been in psychiatric work since the completion of my internship in nineteen thirty-one with the usual interruptions occasioned by sea duty.

3. Q. Captain Raines, how long have you been Chief of the Neuropsychiatric Service at the Naval Hospital?

A. Since May third, nineteen forty-five.

4. Q. Have you recently had a patient under your care by the name of James V. Forrestal?

A. Yes.

5. Q. When was Mister Forrestal admitted to this hospital?

A. At about seventeen hundred on Saturday, April second, nineteen forty-nine.

6. Q. Under what circumstances was Mister Forrestal admitted to the hospital?

A. On Thursday, March thirty-first, about noon, shortly before noon, the Surgeon General called and said that I was to get packed immediately and dressed in civilian clothes and meet Admiral John Gingrich at the Naval Air Station, Anacostia, for a flight south to see a patient. He was quite uncertain as to how long I would be gone or what the situation was or even where I was going. He said that the patient was Mister Forrestal but there were no details concerning the nature of his difficulty. Admiral Gingrich and I landed at Stuart, Florida, at about eight o’clock that evening and were met and taken to the home of Mister Robert Lovett. Mister Lovett, and subsequently Mr. Artemus Gates who was also at the resort town of Hobe Sound[,] gave us some information of what had been going on with Mister Forrestal who had arrived there two days previously. In general, they described an individual who was quite depressed, sleepless and restless. They also told us, which we had not known before, that Mister Ferdinand Eberstadt had been requested by Mister Forrestal to come to Hobe Sound with a physician and Mister Eberstadt was arriving the following day with Doctor William C. Menninger. Under the circumstances I considered it unethical to take any part in the case despite our having been sent there because Mister Forrestal had designated a physician of his own choice. As a result, I remained completely out of the picture and Doctor Menninger arrived late the following afternoon, April first. He examined Mister Forrestal and Doctor Menninger, Mister Eberstadt, Admiral Gingrich and I then had dinner together to discuss the situation. Menninger was of the opinion that Mister Forrestal had a

severe depression which was primarily on a reactive basis and had resulted from excessive work with a lot of very difficult responsibilities. He and Mister Eberstadt discussed hospitalization for the patient at some length, paying particular attention to what type of hospital should be employed and where that hospital should be located. Admiral Gingrich and I didn’t participate in this discussion but were present. Doctor Menninger and Mister Eberstadt then arrived at the conclusion Mister Forrestal should be treated in a general hospital, that the Naval Hospital, Bethesda, provided the best possible facilities available. Among other things that entered in their consideration was that Mister Forrestal was suffering with a recoverable illness, that recovery could be expected in a reasonably short period of time, three to six months, that recovery probably would be complete and that attention should be paid to protecting him from unnecessary stigma or any intrusion on his illness that might subsequently interfere with his life. I had been instructed by the Surgeon General to bring Mister Forrestal back to the hospital if he wished to come so that I accepted him as a patient the following morning, April second. I went back on the evening of April first and simply spoke to him along with Doctor Menninger but actually took responsibility for him the following evening. We were flown back and he was admitted here that afternoon.

7. Q. Will you tell the Board the results of your observations and treatment of Mister Forrestal, especially in reference to his mental status?

A. Mister Forrestal was obviously quite severely depressed. I called the hospital from Hobe Sound on the morning of the second and asked that they have two rooms available, one on the officers’ psychiatric section and the other in the tower. At that time I had not examined Mister Forrestal, was not at all sure how much security he needed. On the flight up I had opportunity to talk to Doctor Menninger at great length and to see the patient briefly. As a result, I felt he could be handled in the tower satisfactorily, provided certain security measures were taken. Consequently, he was admitted to the tower with a continuous watch when he arrived here. The history indicated that Mister Forrestal had had a brief period of depression last summer but that this had cleared very rapidly when he went on a vacation. His present difficulties seemed to have started about the first of the year, perhaps a little earlier, with very mild depressive symptoms beginning at that time and a good many physical symptoms, noticably [sic] weight loss and constipation. The depression had been rather marked from about the fifteenth of February nineteen forty-nine but had not become actually overwhelming until the week-end preceding admission which would have been approximately March twenty-fifth and twenty-sixth. At that time he became very depressed and I believe as a result of that relinquished his office some three days earlier than had been previously planned. He was seen by Mister Eberstadt on the Monday before admission and on his advice immediately relinquished his office and went to Florida for a rest. The physical examination was done by Doctor Lang immediately after admission which showed nothing remarkable except some elevation of blood pressure. The neurological examination was negative except for small, fixed pupils which, so far as I know, had no significance. Mister Forrestal was obviously exhausted physically and we postponed any complete studies until such time as his physical condition could

be alleviated. He was started immediately on a week of prolonged narcosis with sodium amytal. His physical condition was so bad we had difficulty adjusting the dose of amytal because of his over-response to it. About the third night his blood pressure dropped to fifty-five systolic under six grains of amytal. To prevent any confusion in the orders on the case I selected two of the residents[,] Doctor Hightower and Doctor Deen, and put them on port and starboard watch to begin at five o’clock each evening. The doctor on watch slept in the room next to Mister Forrestal. On Monday after admission on Saturday security screens were provided for the room that Mister Forrestal occupied and for the head connected with it by moving them from tower five. At the same time a lock was placed on the outer door of the bathroom and strict suicidal precautions were observed. I saw Mister Forrestal for interviews daily during the morning of that first week when he was allowed to come out of his narcosis for short periods of time. These interviews were devoted primarily to history-taking. His response to that early treatment was very good and he gained about two pounds during the course of the weeks’ [sic] narcosis. The following week, beginning the eleventh of April we started Mister Forrestal on a regime of sub-shock insulin therapy combined with psycho-therapeutic interviews. This was continued about four weeks but his response to it was not as good as I had hoped it to be. He was so depleted physically he over-reacted to the insulin much as he had to the amytal and this occasionally would throw him into a confused state with a great deal of agitation and confusion so that at the end of the second week I had to give him a three day rest period instead of the usual one day rest period. I am not sure that that was the end of the second or third week. At the end of the fourth week again he was over-reacting to the insulin and I decided to discontinue it except in stimulating doses. From that time on he was carried with ten units of insulin before breakfast and another ten units before lunch with extra feedings in the afternoon and evening. In spite of this he gained only a total of five pounds in the entire time he was in the hospital. His course was rather an odd one, although in general it followed the usual pattern of such things. The odd part came in the weekly variation of the depression. I can demonstrate it and explain. Instead of the depression lightening, instead of straight up in a line he would come up until about Thursday and then dip, hitting a low point on Saturday and Sunday and up again until the middle of the week and down again Saturday and Sunday. Each week they were a little higher. He was moving upward steadily but it was in a wave-like form. In addition, he had the usual diurnal variation, the low point of his depression occurred between three and five a.m. so that the course towards recovery was double wave-like motion, the daily variation being ingrafted [sic] on his weekly variation. The daily variation is very common, the weekly variation is not so common and that was the portion of the course that I referred to as “odd”.

The board then, at 10:10 a.m., took a recess until 10:18 a.m., at which time it reconvened.

Present: All the members, the recorder, and the reporter.

No witnesses not otherwise connected with the investigation were present.

George N. Raines, Captain, Medical Corps, U. S. Navy, the witness under examination when the recess was taken, entered. He was warned that the oath previously taken by him was still binding, and continued his testimony.

Examined by the recorder continued:8. Q. Captain Raines, I show you a clinical record, can you identify it?

A. This is the nursing record of Mister Forrestal. The only portion I don’t recognize is this poem copied on brown paper. Is that the one he copied? It looks like his handwriting. This is the record of Mister Forrestal, the clinical record.

The clinical record was presented to the board as an exhibit. There being no objection, it was so received. A photostatic copy is appended marked “Exhibit 3.”

9. Q. Captain Raines, would you continue your testimony?

The witness requested permission to refer to the clinical record which has been introduced as an exhibit so as to refresh his memory.

The permission was granted.

A. In addition to the further therapeutic measures which have been mentioned we established a rather strict regime of isolation from the outside, primarily because the patient felt quite unable to tolerate visitors. Throughout most of the course of treatment only four physicians were allowed to write orders and it was generally understood that all orders were to be referred to me if I could be reached. The resident medical officers, Doctor Hightower and Doctor Deen, were allowed a certain amount of discretion on the evening watch towards carrying out the orders in detail. As late as the twenty-ninth of April the patient was still quite suicidal and personnel were reminded of this by an order in the chart. A week later the insulin therapy was discontinued and beginning on the eighth of May the patient was placed on the stimulating doses of insulin which I previously mentioned. He continued to improve in the irregular fashion which I have described and by the ninth of May I felt it safe for Mrs. Forrestal to make her plans to go abroad but didn’t think he should go with her. My reason for objecting to his going was, ironically enough, that I knew in the recovery period which seemed at hand the danger of suicide was rather great. The son returned to his work in Paris on May thirteenth. The family was at all times kept fully advised as to the patient’s progress but I didn’t warn them continuously of the suicidal threat nor did I mention it to any one except my immediate colleague, Doctor Smith. By that I mean that I felt my job was to accept responsibility for the patient and that the family should not be unnecessarily troubled or worried by the continual suicide threat. By the end of that week, that is by the fourteenth of May, I felt that daily interviewing could be discontinued and that I could be absent from the city for a period of a week or ten days without disturbing the course of the patient’s recovery. From the ninth of May until the eighteenth which was the last time I saw Mister Forrestal, I had encouraged

him to see people and to extend his activities. He had reached a point in treatment at which it seemed advisable for him to socialize more. I believe he did see a few people that week. He had planned on having some of his friends in this week and saw his business manager momentarily on the afternoon of May twenty-first. The chances on suicide were taken rather deliberately as a part of his treatment. There comes a point in any depressive illness to put some relaxation on restrictions, it has to be given if a patient is to make a complete recovery. Mister Forrestal had reached that point. I was fully aware of the inherent danger but felt that that had to be accepted as a portion of the treatment. That is the general course.

Examined by the board:

10. Q. When you left the city on your temporary additional duty, whom did you leave in charge of the case?

A. Doctor Nardini was in direct charge. The situation was a little complicated because Doctor Smith had to be out of town. I introduced Doctor Nardini to the patient on Monday, the sixteenth. On the afternoon of Tuesday, the seventeenth, I spent quite a long time in interview with Mister Forrestal, perhaps two hours and a half. I saw him again on Wednesday morning for about an hour and my purpose in those visits was, in part, to see what danger might have to be faced while I was away. At the time he was not suicidal and in that considerable period of interviewing I felt well assured that there was no suicidal preoccupation at the moment. That didn’t mean, of course, that it wouldn’t come with the weekend because Tuesday and Wednesday were his best days. Nonetheless, on Wednesday he was better than he had been on the previous Wednesday. Because of the weekly variation in his condition I could never compare day to day but I would have to compare the day to the same day of the previous week.

11. Q. Did Mister Forrestal, throughout his illness, have access to outside communications through the radio, telephone, newspapers, correspondence or people?

A. He had full freedom in everything except telephone and people. We took the telephone out of the room, not because of outgoing calls, but because so many people were calling in and asking and I didn’t want to take the risk of his being disturbed by cranks and what not who could get the calls through. We kept visitors out in part at his own request because he didn’t feel able to tolerate them. One of the last orders I left, however, was to the effect if he wished he could have his telephone in his room at any time and he could use the pay station on the ward at any time. Concerning the security measures if you would like those in more detail, we began relaxing them. I first eased the regulations as a test on the twenty-sixth of April but found that the patient was not ready for it and that resulted in an order on the twenty-ninth of April that the watch was to remain in the room at all times, that the patient was still quite suicidal. The relaxation on the afternoon watch was only a few days later, on May first, which indicates how abruptly his condition would change at times in these undulating moments in the illness. I allowed the special watch to be out of the room from the evening meal until twenty-one hundred beginning the first of May. Five days later

we left the door open into the patient’s room because of the heat in Mister Forrestal’s room. On the seventh of May we allowed the day watch to relax somewhat and an order of that date states that the watch need not remain in the room at all times. It is impossible to put into writing what a special watch needs to know in detail; usually the men were always instructed personally, either by Doctor Smith or myself[,] over and above the written order and this was simply authorization in writing for them to be out. We actually encouraged him to leave his room. It was not our assumption that he would be wandering around the hospital at two o’clock in the morning, that was his own idea. He ordinarily slept with the aid of sodium amytal right through the night and on Friday night I had been told by the resident that he slept through the night without medication. He was in that stage of improvement. He was very close to well actually. When I saw him on the eighteenth I felt we could, didn’t tell him, but felt hospitalization for another thirty days would probably do the trick. He was that close to the end of it. That, of course, is the most dangerous time in any depression.

12. Q. What date did you leave Washington and turn the case over to Doctor Nardini?

A. On May eighteenth. I should say that throughout the conduct of the case while I was in full charge and had full responsibility for it, it was a joint effort by four of us because I didn’t feel that any one person could possibly find his way through that entire matter. As a result of this there was a morning conference with Doctor Smith, Doctor Hightower and myself each day. In addition, Menninger came out in the beginning, twice, looked over the situation. I talked over the course of therapy with him and he concurred in it. I subsequently saw him around May first, the exact date I am not sure of, went over the case with him again and he felt that it was moving along about as was expected.

13. Q. Those residents that were on the port and starboard; were they there in case of emergency or did they have a routine of visiting the patient during the night?

A. They were there primarily for the evening sick call, to be sure that medications, orders, were carried out and in event he needed anything; not limited to emergencies. The night time was a bad time with him always and the two residents were fully as aware of of [sic] his case and how to handle the things he would bring up. His depression began to get deeper in the late evening and very frequently he needed someone to talk to and I felt he had enough of me during the day and there should be someone else during that time. During my absence Hightower spent some afternoons with him in interview but not with any very deep psychotherapy, simply superficial support.

14. Q. Did Mister Forrestal make any attempts at suicide while he was under your care?

A. None whatsoever. The matter of suicide in Hobe Sound, he told Doctor Menninger that he had attempted to hang himself with a belt. Menninger and I were both very skeptical of that and both he and I were of the opinion it was sort of a nightmare. The man

had no marks on him and there was no broken belt. Very frequently a depressed person has a fantasy of dying and reports it as real. So far as I know he never made a single real attempt at suicide except that one that was successful. He was the type of individual, fast as lightening, [sic] of extremely high intelligence and one reason I doubt previous attempts[,] I knew if he decided to do it he would do it and nobody would stop him. He was a boxer in college and his movements, even when depressed, were so quick you could hardly follow them with your eye. In the course of psychotherapy he talked a great deal about his suicide; he would tell me when he was feeling hopeless and had to do away with himself. At those times we would tighten restrictions. He would tell me in symbolic language. One morning he sent me a razor blade which he had concealed. When I interviewed him I said “What does this mean?”. He said “It means I am not going to kill myself with a razor blade”. Of course, he had the blade and could have done it. A man of that intelligence can kill himself at any time he desired and you can’t very well stop him. He is my first personal suicide since nineteen thirty-six, thirteen years ago. The last one was on a locked ward at St. Elizabeth’s [sic] Hospital under immediate supervision of an attendant. We discussed, whenever he felt badly enough, he would talk about the possibilities of killing himself and I am sure that when I left here on the eighteenth he had no intention at that time of harming himself.

15. Q. Had he, in the course of your interviews, either symbolically or otherwise, suggested his method if he committed suicide?

A. Yes, I am sure he didn’t jump out of the window. My interviews with him were for one to three hours a day over a period of eight weeks; can’t go into all the material that makes me think that but by the time he had been here four weeks I was certain there were only two methods he would use because he had told me, one was sleeping pills. He said that was the one way he could do it and the other was by hanging which made us feel somewhat more comfortable about the period of risk, knowing that he wasn’t going out one of the windows. I haven’t gone into all the details of what happened, but personally feel he tried to hang himself. I don’t think he jumped; he may have; don’t think it was out the window; think he meant to hang. For some time he had had complete access to the open windows in the residents’ room and for a short period of time he even slept in there for two or three nights. There were two beds in the residents’ room and he would sleep in one of those until about three o’clock and then go back to his own bed. That was the one thing that puzzled me, when he [Nardini] called me, as to what had happened; I couldn’t believe it because of the window, until I got back and found out about the bathrobe cord.

16. Q. Would you tell us, Captain Raines, the nature of the watch that was maintained in Mister Forrestal’s room?

A. It was a psychiatric watch. I didn’t know the corpsman who was on watch at the time of the suicide. However, I left the selection of the corpsmen entirely up to Doctor Smith and Doctor Hightower who knew them personally much better than I. All of our men have had training in psychiatric safeguards and procedures although only very few of them are certified psychiatric technicians. We conduct a course of our own which runs for six months. I don’t know how long the man on watch had even been here or whether he had had all of that course but know he must have been considered satisfactory to Doctor Hightower or he wouldn’t have been on watch.

18. Q. Will you please state Doctor Menninger’s qualifications briefly?

A. Doctor Menninger is one of the most prominent psychiatrists in the country. He is just completing a term as the President of the American Psychiatric association, the American Psychoanalytic Association and the Central Neuropsychiatric Association, probably the only man in history to hold all three offices simultaneously. He has so many governmental appointments as consultant that I don’t know all of them; on the training committee of Public Health Service, hundreds of them, Veterans committee of National Research Council, etc. Incidentally, for the information of the board, I was with Doctor Menninger at the time I was notified of Mister Forrestal’s death. His attitude was that it was the type of casualty which comes with therapeutic psychiatry; he knew all of the steps that had to be taken. I spent about thirty minutes with him on Sunday morning after the suicide; reviewed the case and he felt that the conduct of the case had been in accord with the principles which had been followed throughout. As a matter of fact, I also have a large number of telegrams and telephone calls from some twenty to thirty psychiatrists throughout the country, including Braceland who is Chief of Psychiatry at Mayo Clinic, beside the people here on my staff and Doctor Menninger. Braceland was the only other individual that know in detail the conduct of the case. He was a personal friend of Mister Forrestal’s and thought very highly of him and I had spent two days with Braceland, on May nineteenth and twentieth, and during that time had brought him up to date on the course of Mister Forrestal’s case. He was at that point in complete accord with what we were doing and called last night, unfortunately I was out, but left word that he would be happy to appear if it were necessary, which was what Doctor Menninger said – if the board of investigation would like to talk to him he would come down. I would personally hesitate to ask Doctor Menninger to come until the end of the week because he is in charge of the meeting of American Psychiatric Association which is having some internal trouble and really should not be here but I am certain if the board wanted a telephonic communication with him he would be glad to help out any way he could.

19. Q. Did Doctor Menninger, at any time, discuss, suggest or agree on the relaxation of safety precautions when the time was appropriate?

A. Yes, sir, we spent a great deal of time talking about the danger period and in trying particularly to find some way of transition from complete strict security to recovery. Mister Forrestal’s prominence was such that it imposed a great burden on trying to make any arrangements in which he could have some freedom of movement. Literally hundreds of people who called about him, who knew about him, and some of those were friends, others were people whose primary interest seemed to be in what they could get out of him. He wasn’t in any position to be exposed to any exploitations by crack pots, [sic] screwballs and whatnots and Menninger and I, and his family and I, and Mister Eberstadt and I, at various times did

a great deal of discussing as to what the move would be in this period of relaxation, how we would get him out of the hospital. I personally, my personal plans were, within the period after I came back, depending on his condition, to move him to tower seventeen where there are no security screens at all and to continue his watch about as it was being continued at the time I left, or more an attending basis than a basis of very strict supervision. It was this period that we were all worried about, as to how it could be accomplished and Menninger and I fully agreed that restrictions would have to be removed as rapidly as the patient’s condition justified. The only hope for recovery in people of that sort is to allow them to gradually take up socialization activities. The confinement of a man to strict isolation routine when he is depressed is very apt to fix the illness; there has to be something to break him away from himself and get him interested in the world outside and people outside. From the very first Mister Forrestal’s mail and other communications were handed to him unopened. He was allowed to see all of them on the theory no one can live in a vacuum and might just as well be exposed to whatever came along; that is the method of dealing with it; it would depend on how well he was or how sick he was. It was as simple as that. Actually, he dealt quite well with almost everything. It is my own feeling from what I know that the period of despondency which caused him to end his life was very sudden in onset and probably the whole matter was on an impulsive basis. That was the one thing I had feared, knowing of his impulsivity. Again I say he moved like lightening, [sic] some of those on pure impulse. That is supported by several things. I talked to Doctor Hightower last night and was glad to hear him say spontaneously and not just in agreement with me that he felt that this was an impulsive thing of sudden origin, but one of the main evidences is the complete absence of any suicidal note or expression of suicidal intent in any way. He left no message at all except this poem which I am sure was meant for me and was not a portion of the suicide. That is to say, I think he was simply writing that out to demonstrate how badly he felt. People who contemplate suicide almost invariably leave some note to someone and usually someone close. The absence of some note would make me feel this was a very impulsive act of the moment. Mister Forrestal was still being carried Under [sic] DU [Diagnosis Undetermined] Medical Observation but the psychiatric diagnosis was reactive depression. Clinically, the depression was of mixed type but in the present nomenclature the best diagnostic term applicable is Reactive Depression. There were very strong reactive elements in it. It is the type of depression which we saw very frequently during the war; sixty to ninety day depressions in reaction to excessive work or complete change in a man’s life. He had reached a point at which the entire life had to reoriented with giving up of his job as Defense Secretary which he knew was coming some time back. Everything had to be changed; his whole method of living which had gone on for about nine years and at his age that sort of rearrangement is a difficult task. Many people go through this sort of thing in lesser degree. His, I think, was especially severe because he was worn out.

20. Q. Before he came to Bethesda while he was down south, did he make any attempt to slash his wrist?

A. No, he had a small scratch on his wrist which he told me was not a suicidal attempt but he was considering it and he was wondering what he could do to himself and he took a knife or blade and scratched his wrist, so superficial it was not even dressed, and wouldn’t come under the heading of “attempt” so far as I am concerned. There is one thing about the treatment. We considered the possibility of electro-shock but felt that the reactive portion of the illness was so prominent that we should withhold electro-shock for at least ninety days. In reactive depressions if electro-shock is used early and the patient is returned to the same situation from which he came there is grave danger of suicide in the immediate period after they return. Of the last two or three people who have jumped from bridges in town here two of them, to my knowledge, were electro-shock cures of short duration, so strangely enough we left out electro-shock to avoid what actually happened anyhow.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

I would like to stress one point and that is that the responsibility of the case was entirely with me. I had nothing but the most complete cooperation from the hospital authorities here, from Mister Forrestal’s friends, and from his family. I shared the conduct of the case with selected members of the staff because I needed their assistance but all of the direction of the case and the complete control of it was entirely in my hands. I would like to make that a matter of record. The problem of responsibility, the responsibility for its conduct was entirely mine.

Neither the recorder nor the members of the board desired further to examine this witness.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

2. Q. How long have you been in psychiatry and what are your qualifications?

A. I have had a special interest in psychiatry since nineteen thirty-two in college and have pursued the study with additional interest ever since. Technically, the first formal medical training period was from June nineteen forty-six to June nineteen forty-seven as Executive Officer and Resident in Training at the U. S. Naval Medical Unit, U. S. Public Health Service Hospital, Fort Worth, Texas. From July, 1947 to the present time I have been serving in my present assignment as officer in charge of the neuropsychiatric service of this hospital. My official status is on the staff.

3. Q. Would you please tell the board all that you know relative to your participation in the treatment of the late James V. Forrestal?

A. Just prior to Doctor Raines’ departure on Wednesday, May eighteenth he had indicated to me that he would like me to take administrative charge while he was gone. In preparation for this the first time that I met Mister Forrestal was for the purpose of being introduced to him on Monday afternoon, the sixteenth of May. I next saw him on Tuesday morning along with Doctor Smith briefly and then I saw him alone again for brief periods on the mornings of Thursday, Friday and Saturday. My primary administrative role was to handle all incoming calls, to decide whether or not visitors who wished to see Mister Forrestal should be permitted to see him, to take up with him directly his choice of wanting to see any particular visitors and to handle any inquiries that came from outside on either a professional or personal basis on all matters relative to his case. Since Doctor Hightower had been in more complete and earlier contact with the case and Doctor Hightower knew the case it was felt that he should continue to deal with the more personal aspects of the case and Doctor Hightower and I conferred at various times regarding Mister Forrestal’s condition. The feeling that I had regarding his condition, based upon my own observations and conferences with Doctor Hightower, was that his condition remained essentially the same. Most of my conversations with him were on a more or less impersonal nature with no serious attempt to enter into the actual therapeutic situation. I last saw Mister Forrestal on Saturday morning about ten o’clock at which time he seemed to be about the same as he had been on the preceding few mornings. About zero two ten Sunday morning I received a phone call from Doctor Deen in which he informed me that Mister Forrestal had gone through the window and his body was found below. I then called Doctor Raines in Montreal, Canada, and informed him of the situation and told him that I would come to the hospital immediately to do whatever was required.

Examined by the board:

4. Q. Doctor, during your period of supervision of this case was it necessary for you to change or issue any new orders?

A. No, sir, I considered his condition to remain essentially the same and made no change of any of the existent orders.

5. Q. When you took over charge of Mister Forrestal were you familiar with the various aspects of his case?

A. Yes, sir, in a rather general way. I had a general understanding of his over-all clinical picture, although I had had no active participation in the case up to Monday, May sixteenth.

7. Q. You stated that he was about the same; over what period of time did you have reference to, did you mean from the time he entered the hospital or for the few days you were cognizant of his case?

A. That would only be from the period the first time I saw him on Monday the sixteenth up to Saturday the twenty-first.

8. Q. Saturday was the last time you saw him?

A. Yes, sir.

9. Q. What time?

A. Approximately ten o’clock Saturday morning.

10. Q. And you saw no change in his condition at that time; no evidence of any undue disturbance or agitation or depression?

A. No, sir, he continued his usual discussions; he was rather brief in his discussions. It was rather difficult to reach him in a sense of establishing close personal contact but his intellectual functionings seemed as usual. He gave no increased evidence of tension or depressive features; made no unusual references. Most of our discussions were conversations either of personal life, he usually directing questions toward me about my activities, or some of my background features but since I was not entering into the treatment situation I saw no reason for participating in personal discussions.

11. Q. Then you saw no reason whatsoever to make any change in orders, to tauten up security or take extra precautions?

A. That is correct.

12. Q. Doctor, in the preliminary testimony you stated that there was a dual function, that you, Doctor Nardini, were to handle the incoming inquiries and Doctor Hightower, because he was better acquainted with this case, to handle the professional aspect. In other words, Doctor Hightower handled the professional and you handled the administrative matters?

A. That is essentially true but at the same time the over-all responsibility was mine since I was placed in charge of his case and I conferred for that reason with Doctor Hightower as to his opinions of the more personal phase of the patient’s condition.

13. Q. But you actually didn’t have any psychiatric interviews with Mister Forrestal?

A. Not more than would be derived from conversations I had with him on the mornings of Thursday, Friday and Saturday.

14. Q. Did Mister Forrestal make any attempt at suicide while you had charge of the patient?

A. No, sir, none that I was ever informed of, became aware of, or suspected.

15. Q. Did Mister Forrestal indicate in any way to you that he might do harm to himself?

16. Q. Doctor Nardini, if you had – in your observations of this case and in the absence of Doctor Raines who was in immediate charge, would you have felt free to change any safety precautions that might be taken?

A. Yes, sir, it was understood between Doctor Raines and I if there was any question in the condition of the patient which required any further consideration or attention to get in touch with him immediately.

17. Q. To get in touch with him or take immediate action?

A. I would have assumed either way; if immediate action was indicated I would have felt free to take it or if I had any other questions about it I would have felt free to contact him.

18. Q. But you saw no indication at any time to take action or change any orders?

A. No, sir, I saw no specific indication for changing the course of management or treatment.

19. Q. There was a hospital corpsman on watch on Mister Forrestal, was there not?

A. Yes, sir.

20. Q. But he was not required to be in the room?

A. Not at all times at this stage.

21. Q. Did he have orders to check up on him every so often?

A. His orders were to be with the patient most of the time but that he could leave the room as desired for purposes which were indicated.

22. Q. Do you remember the man on watch between the midnight and two o’clock Sunday morning on the twenty-second?

A. Yes, sir, that was a corpsman by the name of Harrison.

23. Q. Is he designated as a neuropsychiatric technician?

A. No, sir, but he had had a degree of training on the neuropsychiatric service in the closed wards which would be enough to give him sufficient understanding of this type of problem.

24. Q. Were you and Doctor Hightower in full accord that the safety precautions were adequate at the time?

A. Yes, sir, based on my understanding of the case as derived from Captain Raines and my conversations with Doctor Hightower that there had been no perceptible change in the patient’s condition and also my own observation. I had observed no perceptible change in the patient’s condition.

25. Q. You had had conversation with Doctor Hightower about it, is that right?

A. Yes, sir.

26. Q. Is this corpsman that had the watch from after twelve o’clock – was he aware of the suicidal tendencies of Mister Forrestal and had he been instructed to watch against suicide?

A. To the best of my knowledge he had been informed of the nature of the case and written instructions for the corpsmen were detailed in the chart, and, in addition, there was a doctor in constant attendance at the spot where he could obtain any additional information or understanding as desired.

A. No, sir, none that seemed to me any more different from his usual attitude of the preceding mornings.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement concerning the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.

The board then, at 12:04 p.m., took a recess until 1:15 p.m., at which time it reconvened.

Present: All the members, the recorder, and the reporter.

No witnesses not otherwise connected with the investigation were present.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

3. Q. How long have you been a neuropsychiatrist in this resident status?

A. Since I reported to the Naval Hospital on October eighteenth, nineteen forty-six.

4. Q. Would you please tell the board all you know relative to your connection with the treatment of the late James V. Forrestal?

A. My first knowledge of Mister Forrestal’s case was on Sunday afternoon, April third, after his admission to this hospital on Saturday, at which time I was called at home by Captain Smith and told to report to the hospital that afternoon and be prepared to spend the night. I reported to the hospital and to Captain Smith and was informed that I was to stand a special watch, sleeping in the room adjacent to Mister Forrestal’s suite and that my duties, so far as the watch was concerned, were to handle any emergency that might come up during my tour of duty at night and also to keep Doctors Smith and Raines, who were handling the case, informed of what was going on. I continued to stand a regular watch at night with Mister Forrestal on alternate nights, to alternate with Doctor Deen. The hours to be covered were from the end of working hours, approximately sixteen thirty, until the beginning of working hours the next morning at zero eight-thirty. In the mornings Doctor

Smith would visit Mister Forrestal briefly and Doctor Raines usually saw him in the afternoons. After Mister Forrestal was started on sub-shock insulin therapy my duties were increased to the extent that I was to report and remain in the room with the patient for the last thirty minutes of the insulin therapy period. This therapy period was usually started at eight o’clock and terminated at eleven hundred. So, on the days that he received insulin I was with him from approximately ten thirty to a few minutes after eleven hundred. After the insulin therapy was discontinued I went back to my old schedule of on every other night. When Doctor Raines left town he asked me to make a point of sitting with Mister Forrestal at some time during the day every day. This I took to mean in the afternoons at the times that Captain Raines had ordinarily been seeing him and on Wednesday, Thursday, Friday, I did sit with Mister Forrestal for anywhere from forty-five minutes to an hour and a half and sat with him briefly on Saturday morning. That about covers the whole time as to when I was actually there.

Examined by the board:

5. Q. Were you fully aware of the various phases of Mister Forrestal’s condition from shortly after he was admitted as a patient to the hospital?

A. Yes, sir, Doctor Raines, Doctor Smith, Doctor Deen and I had discussed at intervals various procedures and therapeutic efforts that were being made during the course of the entire case.

6. Q. During the period of his stay in the hospital did you feel that he was making some gradual improvement?

A. Yes, sir, my feeling from the first was that he was pretty overly depressed, as evidenced by his lack of interest in his surroundings, interest in personal contact with me on the brief occasions that I saw him, whereas as the case progressed, particularly during the insulin period[,] he seemed to become more alert, more interested in his surroundings, and particularly interested in what was going on about the floor itself and the hospital.

7. Q. What was your feeling in regard to the possibility of suicide during the first few days of his stay in the hospital?

A. My feeling with regard to suicide during the first few days of his stay in the hospital was that it was potentially present, that being based on psychiatric experience with depressed patients. I had no actual factual evidence of any sort which would lead me to be able to say specifically that suicidal thoughts or ideas were present. However, I did feel and consider it a possibility on the basis of general psychiatric knowledge.

8. Q. What was your feeling in regard to the possibility of suicide at approximately the time that Doctor Raines left Washington?

A. At that time I felt that Mister Forrestal had made a definite improvement in the over-all picture from the time of his admission and that the possibility of suicide was much more remote than earlier in the case. There were several observations made during the course of the case which led me to feel this. About two weeks before Doctor Raines left I went up to stand the watch one night and stopped by the room to speak to Mister Forrestal, asked him how he was feeling. He said “About as usual”. We chatted briefly about my medical education and where I lived and what not; then later,

when I came up to go to bed about twenty-two forty-five, he was awake and I asked him how he was feeling. He said “About as usual” but he felt his room was a little stuffy and in view of the fact that two of the windows were stuck and couldn’t be opened I agreed that the room was a little stuffy. He said that he thought possibly he would be able to sleep better if he slept in the room with me, - there being two beds in my bedroom and I said I thought that would be a good idea, it might be more comfortable over there. So he did sleep in the room that I slept in that night. My feelings at this time were that the patient was making an effort to broaden his horizons. I felt that he was lonely and felt the need for friendly contact with other people and also felt at the time that the suicidal possibilities had lessened sufficiently to make it safe for him to remain out of his own room. The danger of suicide had been discussed with Doctors Raines and Smith on several occasions prior to this and we had been encouraging the patient to broaden his activities even prior to this particular incident.

9. Q. At any time while Doctor Raines was away did he appear to you to be preoccupied, worried, disturbed or agitated more than usual?

A. To the contrary, he appeared less preoccupied, worried, disturbed, and particularly less agitated. On Wednesday afternoon after Doctor Raines left Wednesday morning I stayed with him about an hour. The relationship during that hour was as usual. We talked of superficial things such as the flowers in his room, a thorn I had removed from his thumb some time previously. Thursday night he said that he would like to attempt sleeping without his usual medication of sodium amytal and I agreed to that with him for a trial period but insisted that if he were not asleep within a reasonable length of time, I think about an hour, he should take his amytal. On Friday I sat with him for about an hour Friday afternoon. He was slightly more cheerful than he had been on Thursday. The impression that I had of him on Thursday was identical with the impression I had with him on the Sunday before which was a day that Captain Raines didn’t see him. That is to say, his appearance and my feeling for his condition was almost identical.

10. Q. Did you, at any time during Doctor Raines’ absence, discuss his condition with Doctor Nardini?

A. Yes, sir, we talked over almost everything that happened with Doctor Nardini and Doctor Deen.

11. Q. During this period did anything come up that made you think that you should tauten up on his privileges any?

A. No, sir, to the contrary. The things that did come up, the feeling I had was if anything, privileges should be extended. We didn’t increase any privileges during this period because we didn’t have Captain Raines or Captain Smith aboard to discuss the matter and we figured we would let the standing orders that they had left when they left remain. However, those orders were, we felt, relatively lenient and that Mister Forrestal was fully capable and able to go along on that line without any change either to increase or to decrease the restrictions that were in effect at that time.

A. Saturday morning when I woke up, having slept in the room next to his with both the doors opened through the bathroom with my bed arranged so that I could look directly into his room and he could look directly in my room, I got up, dressed, went in and spoke to him, asked him the kind of night he had. That night, Friday night, he had slept the entire night with no awakening periods that I know of at all without a sedative. On Friday night he had gone to bed while I was in the room sitting with him. While I was sitting with him Friday night he said he felt sleepy and got in bed. Shortly after he had been in bed for a little while I left and checked with the corpsman about nine o’clock to find out had he taken his amytal. The corpsman said he was sleeping so I said “Well, don’t wake him up to give him some amytal.” My understanding was that he slept the entire night.

14. Q. What was your final impression of him when you left him Saturday?

A. I saw him again Saturday morning at which time an old friend of his from New York came down to visit, a Mister Strieffler. We had been informed by Captain Raines on Thursday night that Mister Strieffler would be down Saturday morning and he had permission to visit. I had told Mister Forrestal on Friday afternoon that Mister Strieffler would be down Saturday morning. He had no comment. My impression Saturday morning was that his condition was about as it had been for the last several days. He didn’t appear to be particularly depressed, neither did he appear to be particularly cheerful.

15. Q. Then you left him Saturday feeling very comfortable about his condition?

A. Saturday noon I spoke to Doctor Deen as he was taking over the week-end watch and told Doctor Deen that I felt the week-end coming up would be about as usual which was my feeling and considered the possibility of dropping back by Sunday afternoon to sit with him as I had been doing along alright, that that would not be necessary and didn’t plan to come over on Sunday afternoon to sit with him.

16. Q. Did Mister Forrestal, in the times you would be with him, express anything about international affairs, discuss them with you?

A. No, sir.

17. Q. Do you think he was trying to get away from such things?

A. I didn’t have much feeling about whether he was or not. He never made any effort to talk along those lines when I was with him, no, sir. In fact, the basis of most of our conversations were relatively superficial, having to do with things of the moment; should he take his sleeping pills or not; was I going to sleep in the room next to him or not; how was the rose thorn in his finger getting along; or whether his constipation was being taken care of or not. Another one of my duties in the case was to write orders for his bowels and I had done that earlier in the course of the case.

18. Q. During your conversations with him did he show any interest in discussing any current events or anything outside of himself?

A. Only once. He asked me on several occasions did I plan to remain in the service if the service treated me as well as it had in the past but with all of the changes in prospect relative to the Navy and the services I was standing by to see how some of those came out and keeping an open mind on the subject. He evidenced considerable interest at that time saying that he had been in on the unification deal and said that he felt that it was a good thing and would probably work out to everyone’s advantage. This was said in a rather round-about fashion and not specifically a direct quote. I don’t remember the exact words.

19. Q. Did he ever discuss any of the lighter things like baseball?

A. He discussed briefly golfing with me once, merely to say that he had been a golfer at one time and that’s about all so far as the lighter things were concerned.

20. Q. Were the windows in Mister Forrestal’s room locked on the Saturday morning that you last saw him?

A. Two of them were unlocked, two locked.

21. Q. Could those windows be opened to permit a person to go out through those windows?

A. No, the window screens on Mister Forrestal’s room were; there were a total of four security screens. In the room itself three screens, two on one side, one on one side, fourth in the head. In the installation of the security screens the two screens nearest his bed were warped and couldn’t be opened or closed without getting a part of the scale that was in the room and taking two people to prize and push and twist to open and close it. I know this because the corpsman and I tried one of them out about a week or week and a half before the case ended. In the entire area the overhead drops down about eighteen inches in front of the windows which were offset. These security screens open inward and hit on this overhead long before they can be opened and when we opened these two they were warped. One afternoon to raise the windows – it was a sultry day, one of the thunderstorm afternoons – the corpsman that was on, quite a small fellow, and I were working on it and I remember distinctly trying to get him to get behind the screen on the window side to try to raise the windows and he couldn’t get in there and following this I didn’t see any point in locking the two warped frames because their purpose of guarding the window was answered whether they were locked or unlocked; namely, they couldn’t be opened sufficiently for even a small person to get out even if they were unlocked. There were no security screens in the doctors’ bedroom and for a period of two or three weeks the door from the head to the doctors’ room had been left unlocked and frequently wide open to improve the ventilation in Mister Forrestal’s room. I tried to encourage him to move about the area after the general feeling among the staff was that his horizons needed to be broadened.

22. Q. At the time that you left him Saturday morning, May twenty-first, did you notice that the ashtray or Petri plate was broken in Mister Forrestal’s room?

A. To the contrary. I noticed that the ashtray Petri plate was not broken before because I recall distinctly using it for my cigarette while I was in there. That had been my usual ashtray when I went in. He had another one by the bed.

Neither the recorder nor the members of the board desired further to examine the witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

My impression of the entire case was that Mister Forrestal was admitted to the hospital in a definitely depressed condition, was quite ill and that during the course of his stay in the hospital his improvement was gradually upward at all times with minor day-to-day fluctuations in mood. My viewpoint during the entire case was a hopeful one and in all my contacts with the patient what few efforts I made to talk with him were aimed along hopeful lines for a complete return to his normal way of life.

Re-examined by the board:

23. Q. Doctor, did you know the night corpsman who was on duty with Mister Forrestal Saturday night extending into Sunday morning?

A. Yes, sir.

24. Q. What was his name?

A. His name was Harrison.

25. Q. Did you regard him as being a suitable and competent watch for Mister Forrestal during those hours?

A. Yes, sir.

The board did not desire further to examine the witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

A. I have been in residency status since December nineteen forty-seven when I reported here at Bethesda. Since that time I have been continually on the psychiatric service except for three months last fall when I was on neurology and I am at present again on neurology, having been on neurology since April first, nineteen forty-nine.

4. Q. Will you please tell the board all you know relative to your connection with the late Mister Forrestal?

A. When Mister Forrestal first came to the hospital as a patient I was designated as one of the two residents to stand night calls, you might say. We were instructed by Doctor Raines that we would be on hand any time we were needed and that we should sleep in the room which adjoined the room of Mister Forrestal. The watch, or call, both apply, began on the days we had the call at four-thirty and extended through next morning until eight-thirty. On weekends, we split it port and starboard, would have week-end duty beginning at twelve noon on Saturday extending through ’til eight-thirty on Monday. Our duties were primarily to be at hand if any question arose in the carrying out of the orders that were written for Mister Forrestal, to give assistance to the corpsman or nurse if they so desired, to make our routine rounds and visit the patient and on any matter which we didn’t feel qualified to handle (I am referring to Doctor Hightower when I say “we”) we were to get in contact with either Doctor Smith or with Doctor Raines. The past week since Doctor Raines was away Doctor Nardini had been designated as the administrative officer-in-charge and in case of any difficulties during that period, the period when we couldn’t contact Doctor Raines or Smith, we were supposed to get in touch with Doctor Nardini.

5. Q. When was the beginning of that watch with reference to date?

A. I can’t say for sure so far as the date goes but Mister Forrestal came to the hospital on a Saturday. Doctor Hightower had the first duty on Sunday night and I had the duty on Monday night; one of the first week-ends in April but so far as definite day I am not sure.

6. Q. That watch has been continuous since that time up until this past Saturday night, is that right?

A. Yes, sir.

Examined by the board:

7. Q. Were you fully aware of the various phases of Mister Forrestal’s condition?

A. I was not aware of anything that went on in therapy but I was informed and from my own observation had what I thought was a fairly good knowledge of his condition all the time.

8. Q. Did the matter of suicide ever occur to you?

A. It certainly occurred to me ever since the man has been here.

9. Q. How did you regard him from that standpoint for the first few days of his stay in the hospital?

A. Well, of course, on the first few days, it was much longer than the first few days, on admission to the hospital he was under almost continuous sedation and constant watch. After a few days they were able to get screened windows on the room and corpsmen were instructed to stay with Mister Forrestal at all times and if they needed anything from the nurse or corpsman on the outside or from Doctor Hightower and me they went through another corpsman, didn’t leave the room at any time. Following that he was on sub-shock insulin therapy for a period of something like three weeks, I believe, and the man was obviously depressed and any time a man is depressed there is always a consideration of suicide to be kept in mind.

10. Q. How did you regard the progress of his condition from the time of admission to the hospital until the time that Doctor Raines left town?

A. Well, I think it is best to put it this way. From discussions with Doctor Raines, Doctor Smith and Doctor Hightower and from the changes in the orders which permitted Mister Forrestal to have more freedom of movement in that he could go into our bedroom and he could be in the room alone without the corpsman I presumed, I felt that improvement was going along or those measures would not have been put into effect. So far as my personal dealing with Mister Forrestal[,] on his original entry and at the time he was on insulin therapy it was always quite difficult to talk with Mister Forrestal, quite difficult because we had been instructed to try to stay away from things that bore on therapy and for a man like Mister Forrestal you couldn’t very well talk to him about the flowers and bees because he was not interested in them. I could ask questions about his Navy life and that sort of thing but always felt that would be getting into a field I should not be in, the psychotherapeutic field, and for that reason I say I found it difficult to talk with him; would discuss things, primarily me, at his questioning but as time went on there was the opportunity to maybe discuss other things. Don’t know just when it was but when Mister Douglas in London had that accident he talked with me about that. From time to time he would ask me questions about was the duty difficult, was I working hard and so on and so forth so that during the period of time he was here in the hospital I felt he was showing continually more interest in outside activities but, as I said, in the beginning the way I looked at it I felt sure things were going on in discussion with Doctor Raines probably I didn’t know about but which were indications that the man was improving considerably.

11. Q. You did, however, from objective signs form some opinion of your own that he was improving?

A. Yes, sir, I did, the night that this happened. Doctor Raines had encouraged Doctor Hightower and me to see if we could possibly get Mister Forrestal to go for a walk or maybe take him up to the television on the eighteenth floor and on Saturday two times, once about quarter of eight I asked him if he would be interested in going up to see the television and he said “No, thank you, I think I will let it go.” Then again at eleven o’clock or thereabouts I talked with him again. The television, strictly speaking, I think is supposed to be closed around ten-thirty, but is sometimes on a little later. When I came up to go to bed some time before eleven I asked him again if he would be interested in going to the television and he said “No, not tonight.”, but he made it sound like not tonight but a night near in the future I will go up with you.

12. Q. During Doctor Raines’ absence did you observe anything that made you think his privileges should be tautened up?

A. No, sir, I didn’t observe a thing.

13. Q. Did you discuss at any time his condition with Doctor Nardini or Doctor Hightower?

A. Saturday noon, May twenty-first, when I went on watch I saw Doctor Hightower in the chow hall and Doctor Hightower just having come off Thursday and Friday nights was pleased that he had the week-end free and said to me “You will have an easy time of it, everything is going fine.” That was the extent of any discussion. I knew Doctor Nardini had talked with Mister Forrestal on Saturday morning, May twenty-first, and there was very little discussion between us. If he said anything it was of so little importance I forgot what it was.

14. Q. Saturday night, May twenty-first when you went to bed how did you feel about Mister Forrestal’s condition?

A. When I got up on tower sixteen I talked with the corpsman who was on duty. He told me that Mister Forrestal had been resting off and on all evening but that he still hadn’t taken his medication. I told the corpsman that I felt possibly my coming to bed would have some bearing on whether Mister Forrestal went to sleep or not and I thought he probably would go to bed and stay in bed after I came up. At no time has there been, in the past three weeks, any hard and fast rule about whether or not Mister Forrestal should take his sleeping medication although it was always ordered, the reason being that at least since I knew Mister Forrestal he had always complained that he didn’t like the sensation of the medication and always wanted to try to sleep without the medication. I viewed his taking or not taking medication just another indication of his gradual improvement and sort of a stepping-stone to further good health. For that reason at no time did I ever insist that Mister Forrestal would take the nightly medication but on numerous occasions I knew that even though he took his amytal he still would be up maybe one or two times during the night going into the bathroom or at least not sleeping. When I had the duty on Wednesday, the eighteenth of May, I went up about seven-thirty to make my evening rounds. Mister Forrestal was asleep, he hadn’t taken any medication and when I went up again to go to bed in the neighborhood of eleven-thirty he was still sleeping so that was proof enough for me he was able to sleep without taking nightly medication.

15. Q. Can you tell us a little more specifically your impression and what happened on the last night that you had the duty, which was Saturday, May twenty-first?

A. I mentioned previously that when I went up on tower sixteen around eleven the corpsman had mentioned that Mister Forrestal had not been sleeping and then I also previously mentioned that I had discussion with the corpsman at that time. I went in to see Mister Forrestal and that was the time I discussed again with him the possibility of going up and seeing the television. He implied not that night but in the future. I again reminded him if he were not sleeping and could not get to sleep he should take his medications, to which he answered “I will.” For the past, I think it was the second of May[,] I would have to check the record to make sure, since that time the adjoining bathroom door into my room has been left open from time to time. That particular night while we were talking about the television and his taking the medication he said “Are you going to close the door” and I said “Yes, because it is cold and I don’t want to catch another cold.[”] I had had a cold for a couple weeks previously and he knew about it and that was was [sic] one of our subjects of conversation from time to time and he said OK or perfectly alright or something like that so I went into my room, got undressed, went into the bathroom, came back, read the newspaper for a while and from here on in I’m not sure of any times but I would presume that I possibly went to bed about eleven thirty. I wasn’t sleeping and although I realized that these lessening of restrictions on the patient were a part of the treatment in his road to recovery, frankly, at times I was ill at ease about the fact that there were two open windows in my bedroom. Whether or not you realize that some restrictions are relaxed, that some risks have to be taken, I don’t think that removes the concern from the people who might be involved in those risks. This was something that had been discussed with both Doctor Hightower and Doctor Raines. Some nights the door would be locked, other nights the door would be closed, another night the door would be opened but on that particular night the door was closed when I

went to bed but as I was lying in bed at one time I heard a little sort of thud and didn’t know whether the wind was coming through Mister Forrestal’s room and banging the door or venetian blinds banging against the window but anyhow I stayed awake just a short period of time and while I was awake Mister Forrestal walked into my room, stood in front of the window next to the bathroom door, looked out for a half-second, turned around, went back through the bathroom into his room and left the door open. I got up and walked over beside the other bed so I could look into the room and Mister Forrestal was lying in his bed. I got back into the bed again and then I started thinking that, well, I told him the door was supposed to be closed, he’s got the door open, now should I get up and close it or shouldn’t I. I finally decided with the air swishing through and the banging of the door I probably wouldn’t get to sleep at all unless I closed it so I got up to close it and was standing in front of the bathroom door with my back to the door which by that time was about three-quarters shut, I presume from the wind blowing it, and just as I was reaching to the knob to close the door Mister Forrestal who was evidently standing in the bathroom, I didn’t see him but we had a few words. He said “Are you going to lock the door” and I said “Yes, because the wind is coming up and it will be banging and it is getting cold here in my room” and he said “Well,” I’m not sure but something like well, that’s alright and then I said “Haven’t you been sleeping?” He said “Yes, off and on” and I said again “You better take your medication you need the sleep, it will do you good” and he said “Alright I will.” I locked the door, lit a cigarette and was standing there in the dark smoking the cigarette and thought – well, I’ll see if there’s something else in the paper I haven’t read. I turned the light on, put my white coat on – I use it as a sort of bathrobe – and started out to the nurse’s desk to get a drink of water. Just as I went by the galley Mister Forrestal and one of the corpsmen were standing in the galley door. As I went out to the desk I watched him going back into his room with the corpsman. I got the drink of water, came back into my room, read the paper for about three minutes and got back in bed. I didn’t have the slightest idea what time it was; didn’t hear anything else or wasn’t concerned about anything else. The light in the galley went on a couple of times but that [sic] not unusual and the next thing I knew was the corpsman, Harrison, came in, awakened me and said that Mister Forrestal still was not sleeping, what should he do about it. I said something like this – that Mister Forrestal knew that he should take his pills if he were unable to sleep without them and that the corpsman should again remind him that the pills were there and that he should take them if he felt he couldn’t go to sleep by himself. At the same time I told the corpsman to keep a close eye on Mister Forrestal. I don’t know what time that was but after all this happened and in talking with the corpsman and nurse I think it was about one thirty-five or something like that when the corpsman came and talked to me. I went back to sleep again because the next thing I recall was Miss Harty coming into the room; she flipped the light on, don’t know which I was conscious of first[,] and she said “Mister Forrestal is not in his room.” I sat up in bed and as I sat up the first thing that flashed through my mind was that he was wandering around the passageway somewhere and I said “Where is he” and she said “I think he’s out the window” so I quickly got up and by the time I was dressed everybody had been shocked about this thing but you can imagine how shocked I was. I went out once to the nurse’s desk in my white coat without any pants on and then came back into my room to get dressed. By that time there were numerous and sundry and many people, including the Officer-of-the-Day, Doctor Mulry, and I had gone in the galley and looked out the window and saw him down there and then went to the desk and called Doctor Nardini to tell him what had happened. Doctor

Nardini said “Does the Officer-of-the-Day know about it” and I said “Yes, he has just been up here but now that I have called you I will go down to see if he has notified Admiral Stone.”

16. Q. When you retired for the night did you believe that any closer restriction should be exercised?

A. No, sir, I didn’t.

17. Q. Was it usual for Mister Forrestal to get up during the night and to walk around or was that an unusual happening on the night in question?

A. In the previous things I have said I hoped to convey the idea I didn’t think any of his activities that night were unusual in any respect. I knew nights he had a capsule and slept, nights he had capsules and didn’t sleep, nights that he slept without anything. It was not unusual for him in the middle of the night to get up, walk over into our room and walk back into his room. As a matter of fact, on, well, two nights with Doctor Hightower I think and one night I am sure of with me, Mister Forrestal asked if he could come over and sleep in the empty bed in our room which we permitted and discussed with Doctor Raines. Doctor Raines said “It is perfectly alright, the man is lonely and dependent and if you people don’t mind its’ [sic] perfectly alright.” On the nights that he didn’t do that he would, say on at least two occasions when I had the duty, he would come into my room, stand in the door and walk back into his own room. Other nights I have heard him in the middle of the night, three o’clock in the morning or something like that, in the bathroom and I could see nothing unusual, nothing different in the way that he had acted on many previous occasions.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

I think I have mentioned before but would like to add again that I was conscious of the fact that Mister Forrestal had not completely recovered. I was also conscious of the fact if we expected any recovery whatsoever the only way it would be brought about would be by gradual relaxation of the restrictions under which the patient had been originally subjected. In all depressed people there is that chance that has to be taken. It doesn’t leave a lot of people very happy about it but at the same time it is the only thing that can be done I feel in allowing the patient to gradually return to a previous better state of well being.

Neither the recorder nor the members of the board desired further to examine this witness.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

3. Q. Will you give a resume of your qualifications as a psychiatrist?

A. I graduated from Tufts College Medical School in nineteen twenty, interned at Boston City Hospital. During the succeeding twenty-nine years I have spent a major portion of that time in the active practice of psychiatry. Among other positions which I have held are Physician in Charge of the Philadelphia Hospital for Mental Diseases; Clinical Director of the Polk State School in Polk, Pennsylvania; Medical Director of Halbrook Sanitorium, Greens Farms, Connecticut; U. S. Navy from April forty-two to August forty-six at which time I returned to the private practice of psychiatry in Westport, Connecticut, and returned to temporary active duty in the Navy September tenth, nineteen forty-eight. I am a Member of the American Psychiatric Association; the New York Society for Clinical Psychiatry; the Connecticut Psychiatric Society; for the past approximately fifteen years I have been an instructor in psychiatry at the College of Physicians and Surgeons at Columbia University, New York City. I am consulting psychiatrist to the Norwalk Hospital, Norwalk, Connecticut; Grace New Haven Hospital, New Haven, Connecticut; Stamford Hall in Stamford, Connecticut; on military leave from the indicated hospital appointments and at the present time I am also assistant Clinical Professor of Psychiatry at Georgetown University. I was also formerly on the teaching staff at the Medical School at Yale.

4. Q. Captain, will you please tell the board what you know relative to the treatment of the late Mister Forrestal?

A. Perhaps I should begin by saying that the treatment was directed by Captain George Raines who is the chief of the neuropsychiatric service and my role was supportive to his therapeutic endeavors and consultive at any time when it was deemed necessary or advisable. I first met Mister Forrestal on the day of his admission to the hospital which, I believe, was April second and subsequently saw him almost daily until May eighteenth at which time I left on authorized leave and didn’t return until after his demise. Through Doctor Raines and through my daily conversation with the patient I acquired some degree of familiarity with the emotional state which was responsible for his hospitalization. I found him to be a very cooperative patient and at all times quite willing to accept opinions concerning his illness and an expressed willingness on his part to avail himself of all the benefits which might be derived from his hospitalization here and the psychotherapeutic therapy which might be instituted. In the nature of our handling of his psychotherapeutic therapy it was an arrangement between Doctor Raines and myself that he would completely control all the therapeutic measures although I can sincerely state that we compared opinions almost daily, particularly in regard to the behavior reactions of the patient and their import. Inasmuch as it is considered good psychiatric practice to avoid confliction and confusion in treatment, especially as it pertains to the interpretation of psychodynamics, that this rests entirely in the hands of one individual. As a result of this arrangement my discussions with Mister

Forrestal were on a less personal level than would accrue from therapeutic endeavors. However, these conversations had a degree of intimacy and resulted in the establishment of a rapport with Mister Forrestal that I always interpreted as being friendly and comfortable. We talked of many diverse matters that had only a casual relationship to his illness as he was a man who not only was mentally alert but continued to maintain an active interest in all current matters on a level compatible with his broad public service and wide experience. These conversations ran a gamut from a discussion of matters of purely local interest to various philosophies and ruminations that touched on the behavior patterns of all people under various circumstances of stress and his astuteness and acumen were such that his comments and discourses were pregnant with comprehensive significance. As indicated previously, the matter of discussion of the more intimate aspects of his personal problems was left for his interviews with Doctor Raines. This Mister Forrestal and I both understood; that this was the arrangement and for that reason our tendency was to stay on less disturbing subjects. My interviews with him usually would last from fifteen or twenty minutes to perhaps an hour. In evaluating the course of his illness as I observed it he apparently was showing a spontaneous improvement with moderate fluctuations which were not incompatible with the type of emotional disturbance which he showed. I was acutely aware of his depressed state of mind and at times contorted interpretation of his own reaction to his predicament and the situations which might have led up to it although he not infrequently mentioned impending disaster. They were always of vague and non-specific character and had to do with matters which had always been of paramount interest to him, namely, the safety of the country. Many times he expressed uneasiness about the future possibilities and windered [sic] whether or not people were as alert to these potentialities as they should be. Each time he would reassure himself by such assertions as, “I really have no uneasiness about the future of the country, I am certain that that is assured. But the travail might be easier if people perhaps were more concerned about some of these things.” We talked frequently of his recovery and the possible change in his pattern of living which would be possible with more leisure and greater opportunity for diversification of interest and a release from the tremendous pressure which his duties had imposed on him over the preceding eight or nine years. He himself offered the opinion that he should have sensed that his burden had become too heavy many months previously and should have done something to correct it. He regretted that he hadn’t done so. Incidentally, he, on several occasions in connection with this type of thinking[,] had offered the opinion that all men highly placed in public life should be more concerned about their emotional health and even perhaps come to a better understanding of the benefits which would result from a more profound knowledge of the emotional concomitant of continuous tension and strain. Inasmuch as he was a man who suffered with a depression and an interpretation of his own predicament through depressive eyes the matter of his recovery or non-recovery was discussed, even including self-destruction. He, at all times, denied any preoccupation with such thoughts and even though his construction of the future possibilities as they affected him were nebulous he not only agreed but frequently volunteered that he was certain that he would be able to reach a level of adjustment which would bring him greater happiness, especially through more intimate contacts with his family from whom he had felt somewhat separated because of the pressure

of work and also because of the opportunities for less hurried and constructive endeavors which his new freedom would permit. He was actively interested in sports and had participated in them to a considerable extent when he was younger, following the various sporting events, not deeply but enough to be fully informed about them. He was interested in history, especially, and enjoyed discussions that pertained to historical backgrounds of various situations from the time of Alexander the Great on up to the present and often wove a very interesting course into the fabric of his conversation pertaining to these historical and philosophical backgrounds and would draw comparisons and analogies with more recent happenings. To cover the rather intimate conversations which occurred almost daily for six weeks would run the gamut of all interesting subjects that a man of his erudition and background could bring into a conversation. I was more often the listener than the speaker. He did some reading but acknowledged that he found it rather trying and tiresome to attempt reading material of any profundity. He was a man of simple tastes so that repeated inquiries as to things which might make him comfortable or more contented or happier in his present hospitalization were usually met with the response that he deeply appreciated our efforts to be helpful and rather than offer a direct rejection he would usually say “Well, perhaps I will try it a little later.” He frequently commented on the pleasant relations he had with all the people here and was unstinting in this praise of the personnel, the physical properties of the hospital and everything pertaining to it. My observations of his reactions during the period indicated would be that of a man who was experiencing a depressive episode which even in itself, in the absence of organic findings, would be self-limited. He was well preserved physically for his years, having a very youthful way of handling himself in all spheres[,] and he was a very acute person intellectually. He was a man of unfailing graciousness in his reaction to even small favors and in spite of a rather austere exterior he was quite accessible for the discussion of his problems and it was very easy to feel the warmth of his friendliness in any discussions with him. Therapeutically, perhaps, I should indicate that the first week he was rather heavily sedated and this was followed by a period of treatment by sub-shock insulin. At night he did receive sedation. At first this was mandatory but he accepted it without protest and later it was made more optional as he seemed to improve and there were occasions when he expressed the opinion that he felt he could sleep quite well without sedation and would do so. If this was not the case he would be given a medication a little later. He had very few visitors because of the nature of his illness and the restraints which were imposed on visiting for therapeutic reasons. He accepted those limitations without protest and, in fact, was not particularly anxious to have visitors until he himself felt in a better mood for meeting them. Physically, his condition seemed to improve, manifested mostly by his gain in weight which, although not remarkable, was at least a thrust in a favorable direction. I believe he gained about five pounds from the time of his admission but this replaced only a portion of about twenty points which he had lost previously. Supplementary feedings were included to hasten the recovery of his lost weight. At no time did I ever hear him express any uncertaintly [sic] that he would not recover nor did I ever hear him express any threat to destroy himself. In regard to the evaluation of the trend of his

condition it was indicated by his externalization and ability to express confidence in his return to health that his condition could be considered as showing the usual type of improvement expected in this type of illness. There is an unevenness about the recovery from depressed situations so that there were times when he was less animated than at other times but the depth of the depression, as measured by his responsiveness to external stimuli of all types[,] clearly indicated that he was following the course which is seen in depressions which are lifting or recovering. In keeping with what is considered to be intelligent psychiatric measures his privileges were extended in accordance with what seemed to be his ability to handle them. It has been consistently the endeavor of enlightened attitudes in the treatment of mental illness to offer them all necessary encouragement to believe they will again be able to identify themselves with society. Perpetual isolation on a very restricted level could have a very deleterious result even in a self-limited type of depression but we considered that a patient undergoing this type of emotional distress is already the victim of overwhelming feelings of social inadequacy, inferiority and dejection. The converse of that would be the utilization of any measures which would help to persuade him that this was not true. Entirely in keeping with such an interpretation of the therapeutic needs of the patient suffering from this type of illness Mister Forrestal’s privileges were extended. This had been instituted, I believe, by as much as three week [sic] before his death and he handled those privileges very well[,] conforming entirely to the limitations and yet to a considerable extent embracing the enlarged opportunities for socialization. I saw nothing in his behavior nor did I detect anything in his conversations at any time which would have made it consistent to reverse the therapeutic endeavor. Inasmuch as the illness is characterized to a considerable extent by self-deprecating interpretations and because of the moral quality of Mister Forrestal’s make-up it would be very difficult for him to lie and he was confronted at relatively frequent intervals with a full evaluation of the potentials of his illness so that even had we failed to be acutely conscious of over-extending his privileges it is my opinion that he would have constricted them of his own volition. If I were to offer an opinion regarding his ultimate act I would construe it as a very impulsive gesture which could not have been predicted by any means which he revealed either in his conversations or his actions. I would base this opinion not only on my own observation but my discussion with the people who were with him prior to the time of his impulsive act.

Examined by the board:

5. Q. Doctor, were you in agreement with the general principles of therapy and their mode of application in this case?

A. Yes, sir.

6. Q. Captain Smith, I believe you stated that there had been no attempts at self-destruction to your knowledge by the patient in question while a patient at this hospital?

A. Yes, sir.

7. Q. Even though [sic, to be correct he must mean “if” since no attempts are in evidence] there had been such attempts is it still consistent with good psychiatric practice to withdraw restrictions as the patient progressed in recovery?

8. Q. What is your opinion in placing a patient with suicidal tendencies above ground where he may be in a position to fall or to jump from such position?

A. Your question would invite a long dissertation on all potentials of suicide. I have seen patients who hang themselves from door knobs and found it necessary to hold their knees up from the floor while they were doing it. I have known of an instance where a patient cut her throat while the nurse was sitting by her bed reading to her so that self-destruction is a force that is so impelling that it is beyond the ability of the normal mind to comprehend its depth and intensity. The desire to die under those circumstances as I have witnessed it is only comparable to the desire of a normal, healthy person to live and if you could reverse the situations wherein a healthy, normal man is threatened with life extinction and reverse that to the point where you could conceive of a man desiring to die exercising the same force and intensity of purpose it will, in a small way, measure the power behind a suicidal gesture. So far as being above the ground floor is concerned, in many hospitals they keep their most disturbed and suicidal patients on the top floor whether it be ten, fifteen or thirty stories above the ground but in all decency and respect for the prospects of the patient with a self-destructive illness they erect certain safeguards which are assumed to be adequate. Those measures were taken with Mister Forrestal when they were positively indicated but the release of the stringency of those mechanical and physical forces were lessened as he improved. This consisted mostly of giving him a little greater movement about the floor but not much beyond that.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.The witness was duly warned and withdrew.The board then, at 4:30 p.m., adjourned until 9:00 a.m., tomorrow, May 25, 1949.

A. I was sitting in the watch room reading a magazine that night when I heard a loud crash which came like across the passageway which is the Department of Bacteriology. My first thoughts were that a large stove or oven in that room had fell down to the floor. I ran in to investigate what the noise was, looked around the laboratory, didn’t see anything wrong; don’t know what prompted me, just happened to look out the window overlooking the ledge and saw something white laying out there; couldn’t see very well, opened window and looked out and saw a man’s body lying there. Immediately I ran back to the watch room, woke up other man on watch, he was sleeping. I called the Information Desk[,] reported I found a man’s body and to come up to the passageway opposite three seventy-three. I ran back into Bacteriology. I climbed out the window, felt the man’s wrist to see if there was any pulse beating; I didn’t feel any. This other man on watch came. I told him to wake up the Chief who was on watch and notify him what happened. When I was out on the ledge I heard the stretcher coming up from the main floor. I ran out, I was running all the time, and showed them where the body was and there was a doctor and some attendants. The doctor climbed out the window and made his examination and that’s all I had to do with it.

Examined by the board:

4. Q. What time was that?

A. The time that I called the Information desk [sic] was zero one-fifty. That was the exact time which I called the Information Desk. There were two windows; the window from which I first discovered the body was unscreened. It kept falling down. When I went to climb out the window I used the opposite window and pushed out the screen that way. I was there most of the time the doctor was examining him and can say that the body was not moved in any way.

5. Q. To your knowledge, were you the first one to see the body?

A. So far as I know, sir, yes, sir I was. When I called the Information Desk they acted like I was the first one who called them; they didn’t seem to know anything about it previous to my calling.

6. Q. Would you please describe in detail the condition of the body as you first saw it?

A. It was a little dark, couldn’t see very well, but could see that there was a left leg extended in an abnormal condition much below the right one; right leg seemed to be straight out in a natural position, left one laying over it and extending one to two feet below the right leg. I could see that he had a part of his mid-section missing, a gap on his left side seemed to have been cut off and that’s all. He was laying face down. At the time I didn’t notice the bathrobe [cord]; I couldn’t see that well to notice it. Remember seeing something there but didn’t know it was a bathrobe cord or was around the man’s neck. First I knew was when the doctor came up and he had a flashlight and shined the light on the man’s head; that’s the first I saw of the bathrobe cord. When the doctor shone the light you could see one end was tied around his neck and other end extended over toward the left part of his head. It was not broken in any way and didn’t seem to be tied on to anything. I looked to see whether he had tried to hang himself and see whether a piece of cord had broken off. It was all in one piece except it was tied around his neck. I noticed his watch; didn’t notice whether it was working or not but didn’t think to see whether it was running or not; didn’t think about it at the time. His left arm was extended out to the side and that’s how I tried to take his pulse.

7. Q. Do you know the name of the doctor who appeared on the scene?

A. The first doctor who appeared on the scene was Doctor Westneat; I believe he was the junior Officer-of-the-Day that night. The doctor didn’t bring a flashlight. It was brought up, I believe, by a corpsman after the doctor arrived. I am not sure of that. I was outside on the ledge and didn’t see what was going on inside.

8. Q. Can you tell us anything more about the articles of clothing which were on the body?

A. All I noted that was on the body was pajama tops and bottoms; didn’t notice anything particular about them. I went down to the morgue when the body was brought to the morgue. The laboratory watch doubles as morgue watch after ten o’clock and I was down in the morgue when they brought the body in. Doctor Westneat cut off his pajamas. There was no bagroom watch and so I wrapped the pajamas in a sheet and laid them aside with a tag on them marked “Please Save”. Doctor Westneat cut the cord off while cutting off his pajamas and as far as I know he took that with him.

9. Q. Was this bathrobe cord tight or loose about his neck?

A. I couldn’t tell you exactly how tight it was but Doctor Westneat, before he cut it off, he tried to insert his fingers in between the man’s neck; don’t know how loose it was.

10. Q. How long did you stay at the scene?

A. I was at the scene from the time I discovered it until after the doctor came there and stayed there awhile after the doctor was there except for the time when I ran out to tell the stretcher bearers where to come; they were turning down the opposite end of the passageway. I heard the elevator and ran out. That is the only time I left the body after finding it.

11. Q. How long was the body on the roof before it was moved to the morgue?

A. I’m not sure of that time; I believe it was somewhere between four and four-thirty. They were waiting for photographers and also Admiral Stone, Swanson and Willcutts and it was after they gave permission that the body was moved.

12. Q. What was the approximate time? Would you say one or two hours?

A. I believe – I couldn’t say for certain, but I believe it would be about two hours or two and a half hours. The body was logged in the morgue. I logged it in the morgue.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

The bathrobe cord taken from the body of the deceased was presented to the board as an exhibit. There being no objection, it was so received. A description of the cord is appended marked Exhibit 4.

Examined by the board:

11. Q. Could you tell the degree of tightness of this cord around Mister Forrestal’s neck?

A. It was taut, Captain, sir.

12. Q. Who gave you the cord?

A. I wouldn’t say for sure, Captain, I think Doctor Westneat but I don’t know; either he or one of the morgue attendants; they were on the opposite side from where I was standing.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn and was informed of the subject matter of the investigation.

3. Q. Would you please tell the board all you know relative to the events which took place on the night of May twenty-first in regards to the death of the late James V. Forrestal?

A. I was awakened about two o’clock by Eliades and he said that Mister Forrestal had died and I got up and went out to where he was and the Officer-of-the-Day of Medical School and Officer-of-the-Day of the Hospital was there. Everything seemed to be under control and about an hour later I went back to bed.

A. It was laying on the ledge just outside the Bacteriology Media room.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.

The court then, at 11:55 a.m., took a recess until 1:15 p.m., at which time it reconvened.

Present: All the members, the recorder, and the reporter.

No witnesses not otherwise connected with the investigation were present.

The testimony of the following two witnesses was taken out of chronological sequence because one of the witnesses was required to be absent at a later date.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

2. Q. Admiral Stone, as Commanding Officer of the U. S. Naval Hospital what was your connection with the handling of Mister Forrestal’s case?

A. I was aware that he was going to be admitted on April second of this year, the afternoon of the second of April.

3. Q. At that time, Admiral, did you leave?

A. No, sir, I was detached Sunday, April third, and left here at three p.m., checked out with the Officer-of-the-Day the morning of April third.

4. Q. What time did you return?

A. I returned Friday, April fifteenth.

5. Q. From that time on would you tell the board your connection with Mister Forrestal’s case, if any?

A. Well, I was in constant contact. Captain Raines, the Medical Officer in charge, kept me daily informed about his progress and his condition and on numerous occasions, on two occasions, I was up with the Defense Secretary, Mister Johnson, for a visit and also with President Truman when he was out to visit with him and I daily was on the floor but not in the room with Mister Forrestal.

6. Q. What are your feelings in regard to the type of handling and treatment Mister Forrestal received during the period after your return and resuming command of the hospital?

A. I feel that Mister Forrestal had nothing but the best of care; that I have all the confidence in the world in the psychiatric staff of this hospital and I feel that the statement that Captain Raines has made publicly is what he believes and I believe that Mister Forrestal had as good care as he would have received in any institution.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

2. Q. Captain Hogan, would you state what your specific duties were between the periods of April third and April fifteenth?

A. During the period April third to fifteenth I was acting Commanding Officer of the U. S. Naval Hospital, Bethesda, Maryland.

3. Q. As the Commanding Officer during that period what was your connection with the handling of Mister Forrestal’s case?

A. As Commanding Officer during that period my connection with the handling of Mister Forrestal’s case was as outlined in the Manual of the Medical Department for Commanding Officer’s responsibilities on all cases in the hospital.

Examined by the board:

4. Q. What are your feelings in regard to the method of the handling and care in Mister Forrestal’s case?

A. Mister Forrestal had been placed under the direct charge of the Chief of Neuropsychiatric service of the Naval Hospital and placed in a room on the sixteenth floor of the main building which had been secured by screening all windows and the placing of a special twenty-four hour watch on his case. In addition, a medical officer was assigned to be present during the evening hours on the same floor and sleeping in the adjoining room to the patient. All known precautions were exercised and competent personnel were constantly in touch with him. I was fully satisfied during the period that everything was being done for the welfare and protection of the case.

Neither the recorder nor the members of the board desired further to examine this witness.

2. Q. Doctor Westneat, what were your specific duties on the night of May twenty-first?

A. I was the intern on watch at the Admission Desk.

3. Q. Would you please tell the board the events relative to the death of the late James V. Forrestal?

A. At the time that Mister Forrestal fell I was making a phone call on some other business concerning another admission that came in that night and the Chief of the Day came into the admission room quite agitated and said that somebody had fallen out of the tower and would I come immediately? I gave the phone to someone else and went with him and we took a stretcher up to the third floor to the room just inside where he had fallen. I was called at twelve minutes of two and we arrived there at about five minutes of two, the delay being accounted for by a mistake in direction. We didn’t go to the right room at first and when I got there I saw Mister Forrestal’s condition and checked his vital signs and they were absent, and noted his dismemberment which, at that time seemed incompatible with life and I pronounced him dead at that time. The Officer-of-the-Day was called at that time and I immediately had a bed-check made of the tower and his absence, that is Mister Forrestal’s absence, was noted. The Officer-of-the-Day, Doctor Mulry, arrived at two o’clock and noted Mister Forrestal’s condition and he and Doctor Gennaro who was the other intern on watch at that time at the Admission Desk went to perform the duties of notification and Doctor Mulry ordered me to stay by the body until further notification. I did so. The Navy photographers arrived at three fifteen and finished their work at three twenty-five and then when Admirals Willcutts, Swanson and Stone arrived, don’t know exactly what time it was, after they had seen Mister Forrestal Admiral Willcutts ordered me to have the body moved down to the morgue which Doctor Gennaro and I did together using one of the Admission Desk stretchers, at which time the coroner saw the body and made his examination and Mister Forrestal was placed in the morgue. I believe I was through at that time.

Examined by the board:

4. Q. Did you identify the body as that of Mister Forrestal or do you know how and who identified the body as that of Mister Forrestal?

A. I didn’t identify the body as that of Mister Forrestal until he was in the morgue when I think that I could recognize him, not from ever having seen him before but from the pictures in the newspapers. I don’t know who made the definite identification of the body. The only other identification was that his room was empty we found out from the bed-check immediately at two o’clock that morning or thereabouts.

5. Q. Did you remove any of the clothing or anything attached to Mister

A. A watch, and the sash to his bathrobe was tied tightly around his neck.

8. Q. Did you remove that sash?

A. No, I didn’t.

9. Q. Do you know who did remove it?

A. No, sir, I don’t. It was done in the morgue in my presence but I don’t remember who the person was who did it.

10. Q. Did the coroner instruct one of the persons present to remove the sash?

A. No, sir, he instructed them how to remove it.

11. Q. What did he tell them?

A. He told them to cut opposite the knot, the back part, in order to preserve the integrity of the knot.

12. Q. Doctor, did you test how tight that sash was?

A. Yes, I did. I could insert one finger between the sash and neck without any difficulty.

13. Q. You don’t think, then, it was tight enough to prevent the patient from breathing?

A. No, sir, it wasn’t.

14. Q. Can you give the exact time that you pronounced Mister Forrestal dead?

A. Exact time to within a minute, sir; one fifty-five.

15. Q. At the time that you called tower sixteen were they aware that Mister Forrestal was absent?

A. I didn’t call tower sixteen; I ordered it done by one of the corpsmen; ordered them to telephone each ward in the tower and make an immediate bed-check; I didn’t do it myself, sir, because I felt that my presence was more required at the man’s side because at that time we were not sure that he was beyond repair.

16. Q. On your examination of the body did you note any evidence of strangulation or asphyxia?

A. No, sir.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

3. Q. Will you please tell the board the events of the night of May twenty-first in relation to the death of Mister Forrestal?

A. At approximately zero one fifty-five I was awakened and called to the third deck, to room three eighty-four and there outside of the north window I saw a body, apparently dead. By that time the intern acting as assistant Officer-of-the-Day had arrived at the scene and had pronounced the body dead as of zero one fifty-five. A systematic search of all floors on the tower was instigated and the information was received that the room of Mister James Forrestal was empty and that he couldn’t be found on the sixteenth deck. Immediately following this, Admiral Stone, Commanding Officer of the hospital[,] was notified of the death and the tentative identification of the body as that of Mister Forrestal. The Commanding Officer wished to make the notification to higher authorities of the Navy Department and therefore no notification was made by the Officer-of-the-Day’s office. A guard consisting of the civilian guard, the Chief Master-at-arms and laboratory corpsman was placed in the vicinity of room three eighty-four to see that the body and general locale was not changed or molested. Admiral Stone and Admiral Willcutts came to the hospital within a matter of fifteen or twenty minutes and took over further arrangements. At approximately three thirty-five this officer was asked to contact Doctor Broschart, the Montgomery County Coroner. The coroner arrived at approximately zero four fifteen. While talking to the coroner he gave his verbal permission over the phone to move the body if we so desired before his arrival at the hospital.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

It might be noted that the immediate discovery of the body was within a matter of seconds by two laboratory corpsmen including W. H. Eliades, hospitalman second, who determined that the body was dead, went for a stretcher, notified the Chief Master-at-arms, the assistant Officer-of-the-Day and Officer-of-the-Day in rapid sequence.

2. Q. Harrison, what were your specific duties on the night of May twenty-first?

A. My specific duties were to take care of Mister Forrestal.

3. Q. What time did you go on duty?

A. I went on duty at eleven forty-five p.m.

4. Q. Whom did you relieve?

A. Price, hospital corpsman.

5. Q. Could you tell the board what happened from the time you took over the watch at eleven forty-five until the time that you discovered Mister Forrestal was missing?

A. When I took over the watch at eleven forty-five Price whom I relieved told me that Mister Forrestal was still up in his room and that he had been walking around; that he had been reading. Since I didn’t know Mister Forrestal personally, (I had been on the night before, and when he woke up the next morning I didn’t get to talk to him very much, I didn’t know him personally), he introduced me to him and he was very friendly and said “hello” to me.

6. Q. How many times did you speak to Mister Forrestal between the time you took over the watch and the time he was missing?

A. Approximately three or four times.

7. Q. Did you notice anything unusual about Mister Forrestal’s behavior during that time?

A. No, sir, I didn’t.

8. Q. Did he say anything to you that would lead you to believe he was in any way disturbed?

A. I went out to the nurse’s desk to write in the chart, Mister Forrestal’s chart.

14. Q. At what time did you become aware of the fact that Mister Forrestal was missing?

A. At approximately one-fifty a.m.

15. Q. Had you previously spoken to the doctor regarding Mister Forrestal?

A. Yes, sir, I had.

16. Q. At what time was that?

A. That was just before one forty-five before I went back into his room to check to see what he was doing, to see if he was asleep or resting.

17. Q. And then you left the room and went out to the nurse’s desk?

A. To write in the chart, yes, sir.

18. Q. What did you do when you discovered Mister Forrestal was missing?

A. When I went back into the room after I had finished writing in the chart, I went over to my chair where he [sic?] had been sitting while I was in his room before and since it is dark in his room, very dark, my eyes had to become accustomed to the light before I could see anything. There is a chair sitting directly in front of the night light and it is very hard to see anything at all when you first walk into the room so I went over and started to sit down in the chair; by that time I could see enough to see that he wasn’t in his bed. The first thought that came to my mind was maybe he had gotten up and gone into the head and at the same moment the corpsman on duty, Utz, came to the door and told me I had a phone call out at the desk. I told him Mister Forrestal was gone. I went out to the desk and answered the phone call. It was Bramley, the night Master-at-arms of the Neuropsychiatric service. Bramley asked me if Mister Forrestal was alright. I said I didn’t know, that he wasn’t in his bed and he told me to make a thorough check and find out for sure where he was. So I went back into the room and the corpsman gave me a flashlight and I went into the head, looked in the closet, any possible place in the room, and on my way back out in the hall back to the phone I looked into the galley and I didn’t see him in there, either. So I went back to the phone and told Bramley that he was not there.

Examined by the board:19. Q. Just prior to discovering that Mister Forrestal was missing did you hear any unusual noises coming from the vicinity of the diet kitchen?

A. No, sir, I heard nothing.

20. Q. Were you close enough to the diet kitchen to hear if there had been any unusual noises?

A. Yes, sir, I definitely would have.

21. Q. What is your regular assignment in the hospital?

A. I was on night duty on ward 6-D, a neuropsychiatric ward.

22. Q. How long have you been there?

A. Approximately two months, a little over two months, sir.

23. Q. How long have you been assigned to the neuropsychiatric service?

24. Q. How many times did you say you stood watch on Mister Forrestal?

A. Part of Friday night and I took the regular watch on Saturday night.

25. Q. Did Mister Forrestal do very much wandering about his room or corridor Saturday night?

A. He was walking around his room and he did follow me out to the diet kitchen when he asked me for some orange juice and then once after that he was out of his room to drink a cup of coffee.

26. Q. Did he go in the diet kitchen for the coffee?

A. Yes, sir, he did.

27. Q. Were you with him then?

A. No, sir, the corpsman on duty, Utz, was bringing coffee up in a coffee pot at that time. I was out writing my chart and he went past my desk where I was sitting and entering in the chart. He went out towards the galley with this pot of coffee and I heard him mention Mister Forrestal’s name and say something to him and ask him if he would like a cup of coffee. Mister Forrestal said “Yes” and then I heard a noise which would signify he was giving him a cup of coffee and right after that I got up and went out to the diet kitchen. He was coming out with this coffee in his hand. He handed me the cup of coffee and said he was all finished with it. He said I could put it in the galley.

29. Q. About what time was that?

A. That is one time I don’t remember.

30. Q. How was he dressed?

A. He was in his pajamas, sir.

31. Q. Did he have a bathrobe on or not?

A. No, sir.

32. Q. Did you give Mister Forrestal any medication at all that night?

A. No, sir, I didn’t.

33. Q. Did he talk to you very much that night?

A. No, he didn’t.

34. Q. Didn’t he ask you about yourself and where you come from and so on?

A. No, sir, he didn’t say much except when I first came in and was introduced to him. That was when he said “Hello” to me. When I asked him if he wanted his sleeping tablets he told me no, he thought he could sleep without them.

35. Q. Was your station inside Mister Forrestal’s room or was it outside the door?

A. I don’t exactly understand what you mean by that, sir.

36. Q. Were you directed to sit in his room while you had the watch most of the time or could you sit at the nurse’s desk?

A. I was supposed to be in the room except when I went out to make entries in his chart or get something for Mister Forrestal.

37. Q. Were the lights on in Mister Forrestal’s room when you took over the watch – the overhead lights?

38. Q. Did you notice a broken ashtray any time during your tour of duty in Mister Forrestal’s room?

A. No, sir, I didn’t.

39. Q. When you were at the nurse’s desk is it possible for a person to go into the diet kitchen without your observing him?

A. I couldn’t have seen him.

40. Q. Did Mister Forrestal appear cheerful or depressed in the time that you observed him?

A. He appeared neither, sir.

41. Q. Did Mister Forrestal do any reading?

A. Not while I was on watch, sir.

42. Q. After you discovered Mister Forrestal was gone did you go into the galley?

A. About fifteen or twenty minutes afterwards, yes, sir.

43. Q. Would you describe the condition of the window in the area at the time that you went in there, in particular whether the screen was locked or unlocked?

A. The screen was unlocked at that time, sir.

44. Q. Were there any attachments to the radiator?

A. I saw none if there were.

45. Q. Did you notice any marks on the window sill?

A. Sir, at that time I was in such a state that I didn’t notice any marks on the window sill.

46. Q. You did state earlier that you had looked into the galley but no one was there?

A. Yes, sir.

47. Q. You had no reason to examine the galley further?

A. No, sir, I didn’t.

48. Q. Did you see Mister Forrestal’s body at any time later?

A. Yes, sir, I did, in the morgue.

49. Q. Did you recognize the body as that of Mister Forrestal?

A. Yes, sir.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that he had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn and was informed of the subject matter of the investigation.

3. Q. How long have you been taking care of neuropsychiatric patients?

A. Fifteen months, sir.

4. Q. What were your specific duties on the night of May twenty-first?

A. I had the watch on Mister Forrestal from four until twelve o’clock midnight.

5. Q. During the time that you had the watch on Mister Forrestal did you notice anything unusual about his behavior?

A. Yes, sir.

6. Q. Will you tell the board what this unusual behavior was during your watch?

A. Well, sir, at twenty-one ten he started walking the room and it didn’t seem odd at twenty-one ten but when he was still walking the floor at twenty-two hundred that was the first time he had ever walked the floor that long and he was walking the floor for a period of two hours and fifty minutes before I went off watch at twenty-four hundred. And another thing was he went into the doctors’ room adjoining his room and raised the blinds, I would say that was – don’t know exact time – around twenty hundred and he raised the blinds and raised the window and at the time I was at the desk. We had orders we could stay at the desk until twenty-one hundred so long as we checked on him; so I went back to the doctors’ room and the patient was standing at the window. He had raised the bottom part of it up as far as it would go. When I walked in the room he jumped aside. He had the blind to the top and the window up as far as it would go. I walked in the room and he jumped aside. He said “Price, I raised that window. If it gets you in any trouble close it” so he went back through the head and closed the door[,] so I let the blind down and walked out of the room. Just as I got to the door I heard the door to the head open again. He stuck his head out so I went back and closed the head door and locked it and I went back to the desk. I didn’t make any note of it because he has opened windows several times in his own room and the doctors’ room. Only difference was I am usually there with him when he does it. Other than that there was nothing odd that he done that I can think of.

7. Q. How long had you stood watch on Mister Forrestal previous to this particular night?

A. Well, sir, I took over the watch the third day he was up there.

8. Q. Do you know what date that was?

A. I would say it was the fifth of April.

9. Q. And you had stood watches continuously on him since that date?

A. Yes, sir, I had eight in the morning to four in the afternoon, then I went from there to twelve to eight, stood that for two weeks, then went on four to twelve. I have been on four to twelve for a little over three weeks.

10. Q. These occurrences that you have just related in regard to Mister Forrestal’s behavior on that night, did you consider them sufficiently unusual to report them to the doctor?

A. No, sir, I reported his walking the room to Doctor Deen and I put it in the chart and then Doctor Deen asked me how come the door was locked back there and I told him I thought I better lock it being as he raised the blind.

11. Q. Did you attach any particular significance to this type of behavior?

A. No, sir, I didn’t at that time.

12. Q. Had you seen him in the past do things similar?

A. Well, sir, he several times did walk the room. He hated light and walked over to the window shades and if they were open a little too far he would pull it closed.

13. Q. Did Mister Forrestal seem friendly on that night?

A. Yes, sir, he seemed very friendly. I introduced Harrison to him as I left the watch and he shook hands with Harrison and said he was glad to meet him.

14. Q. Did he meet him the night before?

A. No, sir, he was sleeping when Harrison came on watch and hadn’t awakened by the time Harrison went off.

15. Q. Other than the conversation you have given with Mister Forrestal did he say anything else to you on that night?

A. No, sir, he asked me if I thought it was stuffy in the room and he asked that several times since I have been on watch; he liked fresh air. When I was on night watch, twelve to eight in the morning[,] he always got a blanket out for us to wrap around us because he had the windows wide open.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

He started reading a book at about twenty hundred and whenever the corpsman would come in the room he would turn the bed lamp off and sit down in the chair and so far as the writing I don’t know. It appeared that he was but I couldn’t say for sure.

[Was what? As the transcript reads, this and the reference to “the writing” and reading a book have no context. The witness had not been asked about any writing or book and none of his replies had mentioned these things. However, typographically nothing appears to be missing.]

Neither the recorder nor the members of the board desired further to examine this witness.

A. At the present time I am on night duty from ten until seven covering from tower eight to tower seventeen, inclusive, supervising all wards.

3. Q. What were your duties the night of May twenty-first?

A. I was on night duty from ten until seven, covering towers twelve to seventeen, inclusive.

4. Q. Will you please tell the board the events relating to the death of Mister Forrestal on the night of May twenty-first?

A. Yes. I had started rounds, gotten my reports on fourteen, was through there about twenty after ten; made rounds on fourteen, went to thirteen then fifteen and I reached sixteen shortly after eleven. At that time I went in to see Mister Forrestal. He wasn’t in his room. He was out in the galley having orange juice with the corpsman, Price. I spoke to him then and he was very calm and self-assured and quite pleasant. He returned to his room. Then, I think about eleven thirty, I went down to tower ten to relieve the nurse on duty there. It is a dependents’ floor and military female floor. After relieving her I went to supper, returned to tower sixteen I would say approximately one o’clock. I checked on Mister Forrestal then. My corpsman had just found him in the galley and the lights had been out when the corpsman, Utz, went in. Mister Forrestal came toward him. He had some coffee and was quite friendly with the corpsman. Mister Forrestal left the galley and returned immediately to his room. Harrison, the corpsman on Mister Forrestal at that time[,] was charting at the nurse’s desk. I told Harrison that I wanted to be informed if Mister Forrestal didn’t sleep as I was aware of the fact that he had pretended to take his sodium amytal earlier in the evening but it was found he hadn’t, that he had been quite active. I understood that Price, before being relieved of his watch at midnight had discussed Mister Forrestal with Doctor Deen who was on duty. Mister Forrestal, after drinking his coffee, went to bed. I made short rounds and came back and checked on Mister Forrestal again, went into his room. This was at one thirty and he was in bed at that time and I assumed him to be sleeping. I asked Harrison if he thought he was asleep and Harrison thought so. Within seconds after I left the room Harrison came out and told me as soon as I walked out of the room Mister Forrestal asked who that was who had entered the room. The room was in total darkness with the exception of the very small night light which was partially covered by a chair; the light was dim. I sent Harrison in to awaken Doctor Deen and to ask him what he advised about sedation since Mister Forrestal had already refused sedation. The next thing I knew about it it was about a quarter to two when Miss Turner, I was in the office at that time on sixteen doing the night log, when she came up and told me a body had fallen. She had heard

the sound of the body falling and I ran for Mister Forrestal’s room, flipped the light on and he wasn’t there nor he wasn’t in the bathroom. Utz, the floor corpsman[,] had run over to the galley and flipped the light on there and as you entered in the galley you cold see the window open and the screen was ajar. I went in and awakened Doctor Deen at that time and told him Mister Forrestal was not in his room and the galley window was open.

5. Q. Earlier in the evening when you sent the corpsman, Harrison, in to inform Doctor Deen that Mister Forrestal had not taken his sleeping medicine what, particularly happened as a result of this?

A. Doctor Deen told the corpsman if Mister Forrestal wanted to take his sodium amytal he could but not to force it.

6. Q. How long have you been on this particular night detail?

A. At that time I had been on approximately a week.

7. Q. Was it usual for Mister Forrestal sometimes not to take his regular sedation at night?

A. Not usual, but there were nights when he hadn’t taken it; he hadn’t taken it the night before and slept well; refused it the night before and slept well.

8. Q. When he refused to take it was it a refusal to take medicine or just a desire not to take it because he thought he probably could sleep?

A. He thought that he would be able to sleep without it although the corpsman, when Price had given it to him earlier he thought he had taken it and because of his pacing up and down he thought he hadn’t taken it and questioned him and he told him he hadn’t taken them.

9. Q. Had you known of that to take place at any previous time, that is, that he pretended to have taken his capsule and didn’t?

A. Not since I have been on night duty but it seems to me while I was on day duty there that that had happened, cannot remember the particular day.

10. Q. On one occasion?

A. Yes, I seem to remember it having happened before; he didn’t like to take sedation but usually took it.

11. Q. On that particular night in question did you notice that he appeared unusual in any way or more agitated, more disturbed, more distraught than usual?

A. At the time I saw him in the galley close to eleven thirty he appeared his usual self; very cheerful, pleasant but no different than at any time I had ever seen him.

12. Q. So far as you know was it usual for Mister Forrestal to go into the diet kitchen on the floor?

A. I wouldn’t say I thought it was usual. I knew he was having increased activity during the day but not at night.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that she was privileged to make any further statement covering anything relating to the subject matter of the investigation which she thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

I think I should say my reason for being so particularly interested in Mister Forrestal that night was I didn’t like the fact he had been so active earlier in the evening and he hadn’t taken his sodium amytal. I understood from the chart when I came on that he had more or less increased motor activity. He had been quite active and I just thought I, perhaps, should pay a little more attention to him since I knew there was a new corpsman on and I would prefer him remaining in bed than having him move around as freely as he was doing.

Neither the recorder nor the members of the board desired further to examine this witness.

The witness said that she had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

A. Right now I am on night duty. Every hour I make my rounds on my regular patients on tower sixteen.

3. Q. On the night of May twenty-first what were your duties?

A. As usual I made rounds every hour and at twelve o’clock I was relieved to go to chow.

4. Q. Were you the regular night duty corpsman on tower sixteen?

A. Yes, sir.

5. Q. Will you tell the board the events leading up to the time of Mister Forrestal’s death on the night of May twenty-first?

A. As much as I had seen him. I believe it was around nine thirty the regular special watch came out and ordered a half-glass of orange juice which I got. He went back in his room and drank it and I never seen him; thought I heard him stirring, talking to the special watch. I went to chow and came back up. We go down about one o’clock and get some fresh coffee. I went down and come back up and just as I went in the galley, I thought the door was all the way open which it wasn’t, I found out when I bumped into the door with the coffee. I pushed it open and seen him and he come towards me, patted me on the back real cheery like and I asked him if he wanted a cup of coffee which he took and went in his room. Then I heard the special watch bring the empty cup back out and sit it in the galley and that’s the last thing I knew. I never seen the man no more.

6. Q. Had you had any particular dealings with Mister Forrestal previously?

A. No, sir, only when he first come and during the day I was on day work then and detailed certain rooms to clean. That room was my room to clean but we never touched it. The vacuum cleaner and all come up from downstairs, never went in there. Only time I seen him was when we went in the head to swab and that stopped and I never did see him after that. That’s the only other dealings I had with the man.

7. Q. When did you first become aware of the fact that Mister Forrestal was missing?

A. I got a telephone call from the Information Desk to hold a bed-check which I did. I was getting ready to go back to check his room, had checked other patients and the phone rang again and they wanted his special watch to come to the phone so I went there and told him he had a phone call. I got the call approximately one forty-eight; never looked at the clock. When he got the call he come to the phone, went back and he said he wasn’t in there. He said sometimes he used to, when he got lonely, there were two beds in the opposite room, in the doctors’ room, sometimes he would go over and lay down with him. So I gave the boy my regular flashlight I always carry and said go into the head and see if he is there; he come back and said he wasn’t. By that time the nurse come and turned the light on and I went out and turned the galley light on and I seen the screen loose. That’s all I know.

8. Q. Did you see Mister Forrestal on any other occasion on the night in question – on any other occasion than running into him in the diet kitchen?

A. Only nine-thirty when he asked for that glass of orange juice.

9. Q. How did he seem at that time?

A. He seemed very cheerful to me like he did at one o’clock. At one o’clock he patted me on the back, don’t remember just what he said, sounded real cheerful to me. I asked him if he wished a cup of coffee and he said Yes he would like to. He asked me if I was going to have one and I said “Yes” and he poured one out for me, picked his cup up and went back in the room.

Examined by the board:

10. Q. Was Mister Forrestal alone in the galley at the time you brought the coffee up?

A. Yes, sir.

11. Q. Where was the special watch at that time?

A. That was at one o’clock. He was just logging something in his chart, heard me talking to Mister Forrestal and he came right out there.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

A. I am on night duty from eight to twelve just about two nights a week, Thursday and Friday. For some time I was scheduled for the month but the civilian nurse on one twenty-eight got sick and I am over there and Miss Carroll, the relief nurse for the civilian nurse, relieves on one twenty-eight on Thursday and Friday and I take the lower towers eight to twelve.

3. Q. What were your particular duties on the night of May twenty-first?

A. Usually before quarter of two I go down to tower eight before I write the Captain’s log and I had left tower twelve and went down to tower eight and I asked the corpsman how everything was and he said he just gave a man a pill. I happened to look up at the clock. It was just about one fourty-four. [sic] I sat there in a chair for a minute and then I heard this noise. It was a double thud and I said what was that. I said “It sounded like somebody fell out of bed you better check the wing in front” and he went to check the beds and said it was alright so I said “I’ll check the head” and sent him to tower seven to see if it was something down there. That’s when I walked in the bathroom on tower eight. I looked out the window. I just remember thinking in my mind, “Oh, my God, I hope he isn’t mine” and I ran up to tower twelve and told the corpsman to check on Colonel Fuller’s room so he walked into his room and I walked into room twelve thirty opposite his room and looked out the window from there and could see a body distinctly. It was then I really realized it was a body and I thought of Mister Forrestal. So I went up to tower sixteen and told Miss Harty there was a man’s body outside the galley window and he wasn’t mine. We both went into his room and he wasn’t there and we noticed the broken glass on the bed and looked down and noticed the razor blade and told him he was missing and she said it was one forty-eight. Then I walked over towards the galley and noticed the screen was unlocked. That’s about all.

Examined by the board:

4. Q. When you found out the body was not that of one of your patients what made you think of Mister Forrestal?

A. I knew he wasn’t mine and I knew that Mister Forrestal was up there and was being watched.

5. Q. You said you saw his slippers [sic? – she hadn’t, that is, not in the photocopy furnished by the Navy] and a razor blade beside them; where did you see them?

A. The bed clothes were turned back and towards the middle of the bed[,] and I looked down and they were right there as you get out of bed.

A. No, I didn’t see any and the razor blade was dry; there wasn’t anything on that. I remember looking and there wasn’t anything on the glass either.

8. Q. Where was the bathrobe?

A. I didn’t see his bathrobe.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that she was privileged to make any further statement covering anything relating to the subject matter of the investigation which she thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness said that she had nothing further to state.

The witness was duly warned and withdrew.A witness was called, entered, was duly sworn, and was informed of the subject matter of the investigation.

3. Q. Did you perform an autopsy on the remains of the late James V. Forrestal?

A. I did.

4. Q. Will you tell the board the findings of the autopsy as performed?

A. The autopsy on the remains of James Forrestal, the findings were: Multiple injuries extreme of an extreme nature, apparently caused by a high fall on a hard surface which was covered with asphalt and cinder rock. I have here the complete gross autopsy write-up and for the board at this time if they wish I will summarize the main pathological findings of autopsy. These are listed in order as follows: Injuries, multiple, extreme (fall); Multiple simple and compound comminuted fractures of frontal, parietal, sphenoidal and maxillary bones of skull, vertebrae, ribs, bones of arms and legs and pelvis; Transverse section of spinal cord at D twelve; Multiple contusions and lacerations, external; Lacerations of both frontal and right parietal lobes of brain; Rupture of upper thoracic aorta; Hemorrhage, mediastinum; Bilateral hemothorax; Lacerations of lung parenchyma, lower lobes, bilateral; Extensive abdominal lacerations with evulsion of intestine; Extensive intestinal lacerations; Traumatic rupture of great vessels of pelvis; Rupture of bladder; Evulsion of left lower extremity at sacro-iliac junction with almost complete traumatic hemipelvectomy. Cause of death: Multiple extreme injuries apparently caused by high fall on hard surface covered with asphalt and cinder-rocks. Those were the major findings at autopsy. I have here

two photographs that I shall pass over to you. These are photographs of the external injuries, taken just before the time of autopsy. We took two photos, one of the skull and one of the abdomen. I have copies of these and also have the negatives which, if the board wishes, I could turn over.

Examined by the recorder:

5. Q. Captain Silliphant, were there pictures taken of the autopsy of the late James V. Forrestal?

A. There were pictures taken of the external injuries immediately preceding the autopsy.

6. Q. Captain, I show you two pictures, can you identify them?

A. Yes, these are copies of the pictures that were taken of which I have just spoken.

The two photographs were submitted to the board by the recorder and offered as evidence. There being no objection they were so received and are appended marked Exhibits 5A and 5B.

Examined by the board:

7. Q. Doctor, did the brain show any pathological findings beside those of trauma?

A. There were no other pathological findings except those due to the acute trauma.

8. Q. Was there any evidence of strangulation or asphyxia by strangulation?

A. No, there was absolutely no evidence external or internal of any strangulation or asphyxia.

9. Q. Were there any slashes across the wrists?

A. There was a laceration of the volar surface of the right wrist which was a part of the general lacerations due to the recent fall. This wrist, incidentally, contained a large hematoma and there was a fracture of the distal end of the radius and ulna of this particular wrist. However, there was no evidence of any lacerations that would in any way appear to have been self-inflicted either recent or remote.

10. Q. Was there any fracture of the cervical vertebrae as shown by X-Ray of the body?

A. The X-Ray didn’t reveal any fractures of the cervical vertebrae; that is the X-Ray taken prior to autopsy didn’t reveal any fractures of the cervicle [sic] vertebrae.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The witness made the following statement:

The cause of death appearing evident I have no further statements to make.

The record of proceedings of the third day of the investigation was read and approved.

No witnesses not otherwise connected with the investigation were present.A witness was, at his own request, recalled to introduce some additional evidence which he had at hand and was warned that the oath previously taken by him was still binding.

2. Q. Doctor Raines, did you request to reappear before the board to submit some further statements and letters into the testimony?

A. I did, sir, inasmuch as Doctor William C. Menninger was the original psychiatrist in Mister Forrestal’s case I thought the board should know of a letter which I have just received from him, dated May 25, 1949, and headed the American Psychiatric Association in Annual Meeting at Montreal, Canada. It is signed by Doctor William C. Menninger as President of the American Psychiatric Association.

A. I do. I know Doctor Menninger’s signature quite well and this is it without a question of a doubt.

4. Q. Will you proceed to read the letter to the board?

A. The body of the letter which is addressed to me is as follows: “Dear Doctor Raines: I was very sorry to learn of Mister Forrestal’s death. As you know, I have been familiar with the total situation from the beginning and have kept in close contact with what was being done. I fully approved of the treatment outlined for him. As a physician, I know it requires greater medical courage to take reasonable risks in the course of recovery than to retain restrictions which retard the getting-well process. If there is anything I can do to help the public or other parties concerned to understand the unpredictable nature of a person with an extreme, impulsive drive to self-destruction, please let me know.” I have also a number of other letters if you are interested in any of them. They have been streaming in.

Doctor Menninger’s letter was presented to the board by the recorder and offered in evidence. There being no objection it was so received and a photostatic copy is appended marked Exhibit 6.5. Q. If you have some other letters you think would be worthwhile to submit to the board we would be glad to hear them.

A. If the board is interested, here is a letter from Doctor Raymond W. Waggoner, Professor of Psychiatry, University of Michigan and consulting psychiatrist to Selective Service during the recent war. It is addressed to me and signed by Doctor Waggoner whose signature I know quite well; written on hotel stationery from Montreal, Canada, under date of May 25, 1949. “Dear Doctor Raines: I have read the newspaper accounts of the tragic death of Mister Forrestal and I am writing to express my sympathy to his family, physicians and to the United States Navy for the loss of such a vigorous former leader and Secretary. I am also concerned that the widespread publicity might in some way reflect upon the excellence of Navy psychiatry unless there is full understanding by everyone of the necessary risks and hazards which must be faced courageously in the management of such a medical problem. Modern psychiatric treatment requires that certain planned risks must be undertaken on occasion in order to facilitate recovery and rehabilitation. No precautions can guarantee avoidance of tragedy in a patient with powerful, impulsive self-destructive tendencies. To utilize constant surveillance precludes the return of self-confidence in the patient and may arouse irritable uncooperativeness in an individual of determined and forceful personality and thus may defeat the whole plan of therapy. It is my sincere hope that this letter may be of some slight comfort to you and that it will emphasize some of the difficult decisions which arise in the therapy and management of such cases.”.

Doctor Waggoner’s letter was presented to the board by the recorder and offered in evidence. There being no objection it was so received and a photostatic copy is appended marked Exhibit 7.

I would like to say that there are numerous other letters but these two I present first because Doctor Menninger knew the case quite well and

second because Doctor Waggoner pretty well sums up the contents of all the others. There are perhaps twenty from various psychiatrists including one from Doctor Overholser, Superintendent of St. Elizabeth’s [sic] Hospital, and from numerous other people but this, the one of Doctor Waggoner, about summarizes what the rest of them have to say.

Examined by the board:

6. Q. Doctor, upon your return to Bethesda did you view the remains of Mister Forrestal?

A. Yes.

7. Q. Captain Raines, in reviewing the previous testimony we recall that you described a weekly cyclical pattern as part of his general trent [sic] toward recovery. Can you give us any explanation for that pattern?

A. As near as I could tell the increasing depression in Mister Forrestal’s case towards the end of the week was rather directly related to his fear of further attacks by certain commentators who broadcast on Sunday evening. It so happened that these two individuals had been particularly vicious in their personal attacks and he was extremely sensitive about further attacks from them. He was so sensitive about these broadcasts that he refused to listen to them himself but asked that I keep an accurate record of what they said. As he improved he was quite disturbed, and reasonably so, over one Sunday night broadcast which had alleged that he was wildly insane and distorted in his judgement while still a Member of the Cabinet. The content of that particular broadcast, which I recorded, had no basis whatsoever, in fact. Mister Forrestal found that particular broadcast an especially hard one to deal with, as he got better, because there seemed to be no way in which it could accurately be disposed of by him. The most difficult single problem in the management of the case was the wild attitude of certain sections of the press. Mister Forrestal was kept isolated from contacts as a part of his treatment. It was our belief that he needed at least two months of rather complete freedom from contact, even with his friends, to permit a good recovery. His friends and family were totally cooperative in this as they had been in all stages of treatment. Certain sections of the press, unfortunately, were not.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

The record of proceedings of the fourth day of the investigation was read and approved.

No witnesses not otherwise connected with the investigation were present.Captain George H. Raines, Medical Corps, U. S. Navy, was recalled as a witness and was warned that the oath previously taken by him was still binding.

Examined by the board:1. Q. Captain Raines, you have stated that from mid-May the next thirty days were considered to be the most dangerous in the convalescence of Mister Forrestal. Why did you go to Canada during this critical period?

A. The stage of therapy had reached the point where it was necessary for the patient to develop some independence from the therapist. That had been developing rather steadily from about the tenth or eleventh of May. I fix the date at that because it was just prior to Mrs. Forrestal’s departure. This was a normal movement in therapy and one which eventually had to be accomplished to make therapy successful. As I have stated before, Mister Forrestal was very close to recovery and actually I felt that this was the last hump that he had to get over. That is one reason for considering it such a dangerous period. The patient has to undergo a developing independence of his therapist and it is in that period of resumption of his own independent personality that stresses are sometimes too great for a patient. Had I not left town I would have spaced my interviews out to accomplish essentially the same thing. I called the hospital on Thursday night and talked to Doctor Hightower. One reason for the call was to be sure that Mister Forrestal had reacted to my departure as had been expected. I had intended calling on Sunday morning for a further check on his condition.

2. Q. Captain Raines, do you mean that this period of risk was created by the break in close dependence upon the therapist and not by other factors in the chronological course of recovery?

A. No, I think I said that is one of the reasons it is a danger period. The two are not clearly separated; don’t know how to separate all of the factors involved. That is to say, it is chronological and yet is also a function of the therapy; they go hand in hand and I don’t know quite how to separate them in any more clear fashion – they go together.

3. Q. Captain Raines, do you consider that your continued duty at the Naval Hospital would have in any way altered the course of Mister Forrestal’s acts?

A. No, sir.

4. Q. It is noted in Doctor Menninger’s letter that he refers to the “unpredictable nature of a person with an extreme, impulsive drive to self-destruction.” To clarify this statement the board would like to know if you consider this impulsive drive would be a constant factor or one of momentary urge?

A. I felt in Mister Forrestal’s case that the drive which led to his actual suicide was a momentary urge and the grave danger that existed throughout was that we could never have enough security to protect against such a flash of depression; for example, had the entire floor been screened, the fire exits offer an opportunity for suicide, or had he wished, he slept in a darkened room, he could easily have cut his wrist and the corpsman would never notice it until the next morning probably, if it were done under the covers. There were so many suicidal opportunities that could not be removed under any circumstances that this type of impulse was extremely difficult to deal with. There was nothing in his previous history or behavior to indicate that there would be such an impulsive move, but the possibility of it was recognized.

5. Q. Did Mister Forrestal listen to the radio?

A. Yes.

6. Q. Did Mister Forrestal listen to the broadcasts of the commentators that you previously mentioned?

A. No.

7. Q. Was this information as given by the commentators transmitted to Mister Forrestal by you and if so, to what degree?

A. He had access to it through the newspapers and he and I discussed what he had read but I can’t say how much I transmitted to him. He had free access to incoming mail, newspapers, books and there was a great deal of comment about one of the broadcasts which occurred after Mister Forrestal’s admission to the hospital. The comment was editorial and in various syndicated columns.

Neither the recorder nor the members of the board desired further to examine this witness.

The board informed the witness that he was privileged to make any further statement covering anything relating to the subject matter of the investigation which he thought should be a matter of record in connection therewith, which had not been fully brought out by the previous questioning.

1. That the body found on the ledge outside of room three eighty-four of building one of the National Naval Medical Center at one-fifty a.m. and pronounced dead at one fifty-five a.m., Sunday, May 22, 1949, was identified as that of the late James V. Forrestal, a patient on the Neuropsychiatric Service of the U. S. Naval Hospital, National Naval Medical Center, Bethesda, Maryland.

2. That the late James V. Forrestal died on or about May 22, 1949, at the National Naval Medical Center, Bethesda, Maryland, as a result of injuries, multiple, extreme, received incident to a fall from a high point in the tower, building one, National Naval Medical Center, Bethesda, Maryland.

3. That the behavior of the deceased during the period of his stay in the hospital preceding his death was indicative of a mental depression.

4. That the treatment and precautions in the conduct of the case were in agreement with accepted psychiatric practice and commensurate with the evident status of the patient at all times.

5. That the death was not caused in any manner by the intent, fault, negligence or inefficiency of any person or persons in the naval service or connected therewith.

NATIONAL NAVAL MEDICAL CENTERBETHESDA, MARYLANDOFFICE OF THE MEDICAL OFFICER IN COMMAND

June 1, 1949

A review of the evidence in the foregoing investigation into the facts and circumstances leading up to the death of the late Mr. James V. Forrestal reveals:

That the deceased was admitted as a patient to the U. S. Naval Hospital, Bethesda, Maryland, on April 2, 1949. That at the time of his admission to the hospital his condition was what was described by the medical officer in charge of his case, and who is a qualified psychiatrist of some eighteen years of experience in that specialty, as “obviously quite severely depressed” and “exhausted, physically”.

Because of his mental and physical condition, an immediate twenty-four hour a day watch consisting of constant surveillance was established over the patient, adequate orders for the patient’s safety were issued, and a regime of medicinal therapeutics commenced; the latter to alleviate his depressed condition and to build up his physical strength. The patient’s response to the treatment was considered to be good, though of a gradual and irregular nature.

During the period of the deceased’s hospitalization, the psychiatrist in charge of his case, Captain George N. Raines, MC, U. S. Navy, talked with him concerning the question of self destruction. [sic] It was fully realized by Captain Raines and his chief assistant, Captain Stephen M. Smith, MC, U. S. Naval Reserve, a qualified psychiatrist of some twenty-nine years of experience in his specialty, that the deceased considered suicide at times and that a patient with that type of disability is a potential suicide. In view of this knowledge on the part of these two medical officers, adequate instructions were issued to personnel assigned to the constant attendance of the patient as to measures to be carried out to safeguard him.

The record further shows that on April 26, 1949, the restrictive regulations in force in the deceased’s case were eased but that it was discovered that his condition had not improved to the extent to justify such action; therefore, on April 29th an order was issued to the attendants on watch to the effect that they must stay in the room with the patient at all times, for as late as that date it was considered that the patient still entertained suicidal tendencies at times. However, the patient’s condition showed an abrupt change for the better and on May 1st, because of this improvement, the close surveillance was relaxed during the afternoon watch. About May 5th the close watch was further relaxed, the patient’s door was allowed to be left open, on May 7th the day watch was relaxed to the extent that the watch was not required to remain in the patient’s room at all times. The patient’s condition continued to show further improvement to the extent that it was not necessary to administer sedatives each night to provide relaxation and sleep. Toward the middle of May the patient’s condition had improved to the extent that it was considered that “He was very close to well, actually” and that only about thirty days more of hospitalization would be required. About May 18th, due to the improvement in his case, he was encouraged to see and talk with people and to extend his activities. At this time it was considered that the patient had progressed to the point where a well calculated risk of suicide was advisable to be taken as a part of his treatment, to prevent the fixing of a permanent mental stigma in and irreparable damage to the patient’s mind and to aid him in making a complete recovery. The patient was allowed to use the telephone and to make other contacts, within a clearly defined sphere of operation.

[Here the body of the report ends. There is no signature.]

[Appendix]

Exhibits

(The targets of the following links, a series of photostats, are appended to the report, but without this table of contents page, which is provided here to label and organize this material. None of the text from the above horizontal divider down is in the report. We have numbered the Exhibit pages starting with one. Add 97 to get the page number in the Seeley G. Mudd Manuscript Library’s PDF file. The photographic exhibits 2E, 2F, 2H, 2J, 2K are duplicated in PDF pages 4 to 8 with higher graphic quality; we place the better photographs in their proper place in the appendix.)

That concludes the report. Below is a picture of Bethesda Naval Hospital as it appeared about eight years earlier, not long after it was built. The central building or tower has left and right wings which go up only to the sixteenth floor. (The windows above the entrance appear to go from the fourth to the eighteenth floor, and the side wings are two floors less in height.) The picture shows a dark beveled structure on top of the right wing – right when facing the front of the building. Forrestal’s bedroom is on the top floor of the left wing, hidden from view by the bulk of the building.

Below is the central tower about 25 years after the report. You can see Forrestal’s two front bedroom windows on the left at the top (not counting whatever the dark construction is above it). The kitchen/galley window is at the rear of the building opposite the right bedroom window.

An aerial view from the left. Though not individually distinguishable in the picture there are three windows facing left on each floor of the left wing. On the top floor going from the front of the building to the back, the first window belongs to Forrestal’s bedroom, the middle to the bathroom/head, the third to the doctors’ room in the rear.

A distant view from the right.

Below is a recent street map of the Bethesda Naval Hospital area. The hospital faces Rockville Pike, a continuation of Wisconsin Avenue. The report says Forrestal landed in “the northeast corner” of the central building, which must refer to an inward corner. From this we can determine the location of Forrestal’s room, already given above, as follows. The building faces west, therefore he fell in the left rear quadrant. The report also says he fell from the kitchen/galley window, so that window must be at the left rear of the building. Finally, since the window he fell from is on the opposite side of the building to his bedroom, his bedroom must be in the left front of the building.

Here is the floor plan of what was Forrestal’s home for about seven weeks, based on various descriptions in the report and the photographs of the bedroom, head and galley in exhibit 2. It accurately shows which room is connected to which, the lengths of the interior walls are reasonable approximations. The nurse’s desk is to the right, either above or below (that is, forward or rearward) the hallway, since (as described in the report) from the nurse’s desk you cannot see someone going between Forrestal’s room and the kitchen/galley. The doctors’ room probably has a shallow closet like that in Forrestal’s room but there being no description or photograph it is not shown here.